Provider Demographics
| NPI: | 1033409222 |
|---|---|
| Name: | KSK HEALTH SERVICES LLC |
| Entity type: | Organization |
| Organization Name: | KSK HEALTH SERVICES LLC |
| Other - Org Name: | |
| Other - Org Type: | |
| Authorized Official - Title/Position: | MANAGER/CEO |
| Authorized Official - Prefix: | |
| Authorized Official - First Name: | STEPHANIE |
| Authorized Official - Middle Name: | L |
| Authorized Official - Last Name: | KIDD |
| Authorized Official - Suffix: | |
| Authorized Official - Credentials: | LPCC/PCC |
| Authorized Official - Phone: | 440-481-3055 |
| Mailing Address - Street 1: | 6929 W 130TH ST |
| Mailing Address - Street 2: | SUITE 503 |
| Mailing Address - City: | PARMA HEIGHTS |
| Mailing Address - State: | OH |
| Mailing Address - Zip Code: | 44130-7895 |
| Mailing Address - Country: | US |
| Mailing Address - Phone: | 440-481-3055 |
| Mailing Address - Fax: | 440-481-3222 |
| Practice Address - Street 1: | 6929 W 130TH ST |
| Practice Address - Street 2: | SUITE 503 |
| Practice Address - City: | PARMA HEIGHTS |
| Practice Address - State: | OH |
| Practice Address - Zip Code: | 44130-7895 |
| Practice Address - Country: | US |
| Practice Address - Phone: | 440-481-3055 |
| Practice Address - Fax: | 440-481-3222 |
| EIN: | <UNAVAIL> |
| Is Organization Subpart?: | No |
| Parent Organization LBN: | |
| Parent Organization TIN: | |
| Enumeration Date: | 2011-04-09 |
| Last Update Date: | 2014-12-12 |
| Deactivation Date: | |
| Deactivation Code: | |
| Reactivation Date: |
Provider Licenses
| State | License ID | Taxonomies |
|---|---|---|
| OH | 35099315 | 2084P0800X, 2084P0800X |
| OH | E0004052 | 101YP2500X |
| OH | E0900389 | 101YP2500X, 101Y00000X, 101YM0800X |
| OH | 35060650 | 2084P0804X, 2084P0800X |
| OH | E0007819 | 101YP2500X, 101Y00000X, 101YM0800X |
| OH | I0007634 | 1041C0700X, 1041C0700X, 104100000X |
| OH | 6890 | 103TC0700X |
Provider Taxonomies
| Primary? | Code | Type | Classification | Specialization | Group |
|---|---|---|---|---|---|
| Yes | 2084P0800X | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry | Group - Multi-Specialty |
| No | 101YP2500X | Behavioral Health & Social Service Providers | Counselor | Professional | Group - Multi-Specialty |
| No | 2084P0804X | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Child & Adolescent Psychiatry | Group - Multi-Specialty |
| No | 1041C0700X | Behavioral Health & Social Service Providers | Social Worker | Clinical | Group - Multi-Specialty |
| No | 103TC0700X | Behavioral Health & Social Service Providers | Psychologist | Clinical | Group - Multi-Specialty |
| No | 101Y00000X | Behavioral Health & Social Service Providers | Counselor | Group - Multi-Specialty | |
| No | 101YM0800X | Behavioral Health & Social Service Providers | Counselor | Mental Health | Group - Multi-Specialty |
| No | 104100000X | Behavioral Health & Social Service Providers | Social Worker | Group - Multi-Specialty |
Provider Identifiers
| State | Identifier ID | ID Type | Issuer |
|---|---|---|---|
| OH | 12634224 | Other | PROVIDER CAQH # |
| OH | 3349058 | Other | UHC/UBH PROVIDER ID |
| OH | 393335 | Other | PROVIDER MHN (HEALTHNET) ID# |
| OH | 687211 | Other | VO GROUP PROVIDER ID# |
| OH | 11744590 | Other | PROVIDER CAQH # |
| OH | 12638930 | Other | PROVIDER CAQH # |
| OH | 0051324 | Medicaid | |
| OH | 587502 | Other | PROVIDER VO ID# |
| OH | 0084596 | Medicaid | |
| OH | 11753827 | Other | PROVIDER CAQH # |
| OH | 2967384 | Medicaid | |
| OH | 687211 | Other | VO MILITARY ONE GROUP PROVIDER ID# |
| OH | 2908413 | Other | PROVIDER UHC/UBH ID# |
| OH | 687211 | Other | VO MILITARY ONE GROUP PROVIDER ID# |
| OH | 11753827 | Other | PROVIDER CAQH # |
| OH | H063430 | Medicare PIN |
