Provider Demographics
NPI:1124436076
Name:MALONE, KELLY A (QMHS)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:A
Last Name:MALONE
Suffix:
Gender:F
Credentials:QMHS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9 CHESAPEAKE PLZ
Mailing Address - Street 2:
Mailing Address - City:CHESAPEAKE
Mailing Address - State:OH
Mailing Address - Zip Code:45619-1003
Mailing Address - Country:US
Mailing Address - Phone:513-849-8670
Mailing Address - Fax:513-271-0080
Practice Address - Street 1:220 S BREIEL BLVD STE 4
Practice Address - Street 2:
Practice Address - City:MIDDLETOWN
Practice Address - State:OH
Practice Address - Zip Code:45044-5106
Practice Address - Country:US
Practice Address - Phone:513-849-8670
Practice Address - Fax:513-271-0080
Is Sole Proprietor?:No
Enumeration Date:2014-07-23
Last Update Date:2023-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHS.1904198104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0442080Medicaid