Provider Demographics
NPI:1154832483
Name:KECKLEY, KYLE BLAIN (IMFT, LPCC)
Entity type:Individual
Prefix:
First Name:KYLE
Middle Name:BLAIN
Last Name:KECKLEY
Suffix:
Gender:M
Credentials:IMFT, LPCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:434 EASTLAND RD
Mailing Address - Street 2:
Mailing Address - City:BEREA
Mailing Address - State:OH
Mailing Address - Zip Code:44017-1217
Mailing Address - Country:US
Mailing Address - Phone:440-260-8327
Mailing Address - Fax:440-234-8319
Practice Address - Street 1:195 N GRANT AVE STE 250
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43215-2855
Practice Address - Country:US
Practice Address - Phone:888-522-9174
Practice Address - Fax:614-928-9092
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-13
Last Update Date:2020-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHE1901016101YP2500X
OHF.1700025106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Single Specialty
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHF.1700025OtherIMFT
OHF.1700025OtherIMFT