Provider Demographics
NPI:1154546281
Name:MCCARTHY, KELLY SHANNAN (CDMS)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:SHANNAN
Last Name:MCCARTHY
Suffix:
Gender:F
Credentials:CDMS
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:SHANNAN
Other - Last Name:MCCARTHY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4448 ANCHORAGE CT
Mailing Address - Street 2:
Mailing Address - City:HILLIARD
Mailing Address - State:OH
Mailing Address - Zip Code:43026-7815
Mailing Address - Country:US
Mailing Address - Phone:614-876-9712
Mailing Address - Fax:614-876-9713
Practice Address - Street 1:4448 ANCHORAGE CT
Practice Address - Street 2:
Practice Address - City:HILLIARD
Practice Address - State:OH
Practice Address - Zip Code:43026-7815
Practice Address - Country:US
Practice Address - Phone:614-876-9712
Practice Address - Fax:614-876-9713
Is Sole Proprietor?:No
Enumeration Date:2007-04-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHJ009638171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHJ009638OtherCMDS