Provider Demographics
NPI:1457728628
Name:KELLY, LISA (MED, EDS)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:KELLY
Suffix:
Gender:F
Credentials:MED, EDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11083 HAMILTON AVE
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45231-1409
Mailing Address - Country:US
Mailing Address - Phone:513-674-4200
Mailing Address - Fax:
Practice Address - Street 1:11765 HAMILTON AVE
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45231-1128
Practice Address - Country:US
Practice Address - Phone:513-825-7070
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-08-24
Last Update Date:2015-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH21158298103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool