Provider Demographics
NPI:1992168579
Name:LULEY, KELLIE (LICDC)
Entity type:Individual
Prefix:
First Name:KELLIE
Middle Name:
Last Name:LULEY
Suffix:
Gender:F
Credentials:LICDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:50 W TECHNE CENTER DR
Mailing Address - Street 2:B 5
Mailing Address - City:MILFORD
Mailing Address - State:OH
Mailing Address - Zip Code:45150-8403
Mailing Address - Country:US
Mailing Address - Phone:513-753-9964
Mailing Address - Fax:
Practice Address - Street 1:4560 STATE ROUTE 222
Practice Address - Street 2:
Practice Address - City:BATAVIA
Practice Address - State:OH
Practice Address - Zip Code:45103-9778
Practice Address - Country:US
Practice Address - Phone:513-753-9964
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-04-01
Last Update Date:2016-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH131013101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)