Provider Demographics
NPI:1962809442
Name:EVANS, KELSEY (LISW-S, LICDC)
Entity type:Individual
Prefix:
First Name:KELSEY
Middle Name:
Last Name:EVANS
Suffix:
Gender:F
Credentials:LISW-S, LICDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3649 CANFIELD RD
Mailing Address - Street 2:
Mailing Address - City:CANFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:44406-9385
Mailing Address - Country:US
Mailing Address - Phone:330-270-3040
Mailing Address - Fax:330-270-1996
Practice Address - Street 1:3649 CANFIELD RD
Practice Address - Street 2:
Practice Address - City:CANFIELD
Practice Address - State:OH
Practice Address - Zip Code:44406-9385
Practice Address - Country:US
Practice Address - Phone:330-270-3040
Practice Address - Fax:330-270-1996
Is Sole Proprietor?:No
Enumeration Date:2014-11-26
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0081939Medicaid