Provider Demographics
NPI:1992315402
Name:LEE, KISHA (CDCA)
Entity type:Individual
Prefix:
First Name:KISHA
Middle Name:
Last Name:LEE
Suffix:
Gender:F
Credentials:CDCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:831 KLING ST
Mailing Address - Street 2:
Mailing Address - City:AKRON
Mailing Address - State:OH
Mailing Address - Zip Code:44311-2200
Mailing Address - Country:US
Mailing Address - Phone:330-812-1664
Mailing Address - Fax:
Practice Address - Street 1:1815 W MARKET ST
Practice Address - Street 2:
Practice Address - City:AKRON
Practice Address - State:OH
Practice Address - Zip Code:44313-7000
Practice Address - Country:US
Practice Address - Phone:330-379-0667
Practice Address - Fax:330-379-0667
Is Sole Proprietor?:No
Enumeration Date:2020-08-10
Last Update Date:2024-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
172A00000X, 374U00000X, 171M00000X
OH140841101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No172A00000XOther Service ProvidersDriver
No374U00000XNursing Service Related ProvidersHome Health Aide
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)