Provider Demographics
NPI:1427677921
Name:WIECZOREK, KELLY A (LPCC)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:A
Last Name:WIECZOREK
Suffix:
Gender:
Credentials:LPCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6500 ROCKSIDE RD STE 385
Mailing Address - Street 2:
Mailing Address - City:INDEPENDENCE
Mailing Address - State:OH
Mailing Address - Zip Code:44131-2353
Mailing Address - Country:US
Mailing Address - Phone:216-468-5000
Mailing Address - Fax:
Practice Address - Street 1:6500 ROCKSIDE RD STE 385
Practice Address - Street 2:
Practice Address - City:INDEPENDENCE
Practice Address - State:OH
Practice Address - Zip Code:44131-2353
Practice Address - Country:US
Practice Address - Phone:216-468-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-14
Last Update Date:2025-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YP2500X
OHE.2404015101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2871101Medicaid