Basic Information
| Provider Information | |||||||||
| NPI: | 1114414174 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ACHBERGER | ||||||||
| FirstName: | KELLI | ||||||||
| MiddleName: | MARIE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | CDCA | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | BUSH | ||||||||
| OtherFirstName: | KELLIE | ||||||||
| OtherMiddleName: | MARIE | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 615 ELSINORE PL STE 200 | ||||||||
| Address2: | |||||||||
| City: | CINCINNATI | ||||||||
| State: | OH | ||||||||
| PostalCode: | 452021459 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5138347063 | ||||||||
| FaxNumber: | 5138731567 | ||||||||
| Practice Location | |||||||||
| Address1: | 6527 COLERAIN AVE | ||||||||
| Address2: | |||||||||
| City: | CINCINNATI | ||||||||
| State: | OH | ||||||||
| PostalCode: | 452395537 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5138347063 | ||||||||
| FaxNumber: | 5138731567 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/16/2018 | ||||||||
| LastUpdateDate: | 10/23/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 10/23/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | CDCA.165953 | OH | N | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 175T00000X | CDCA.165953 | OH | N | 101YA0400X | CDCA.169323 | OH | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
No ID Information.