Provider Demographics
NPI:1972049203
Name:LEE, KELLY (LISW-S, LICDC)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:LEE
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 1:1127 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:ZANESVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:43701-3147
Mailing Address - Country:US
Mailing Address - Phone:740-454-1266
Mailing Address - Fax:740-454-7650
Practice Address - Street 1:1127 W MAIN ST
Practice Address - Street 2:
Practice Address - City:ZANESVILLE
Practice Address - State:OH
Practice Address - Zip Code:43701-3147
Practice Address - Country:US
Practice Address - Phone:740-455-1266
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-10
Last Update Date:2018-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHLICDC.161384101YA0400X
OHI.1600353-SUPV1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0201681Medicaid