Basic Information
| Provider Information | |||||||||
| NPI: | 1366800500 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CARL | ||||||||
| FirstName: | KEARY | ||||||||
| MiddleName: | LEE | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 434 EASTLAND RD | ||||||||
| Address2: | |||||||||
| City: | BEREA | ||||||||
| State: | OH | ||||||||
| PostalCode: | 440171217 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4402342006 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 3500 CARNEGIE AVE | ||||||||
| Address2: | |||||||||
| City: | CLEVELAND | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441152641 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4402608300 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/02/2016 | ||||||||
| LastUpdateDate: | 12/04/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/04/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | C.1400261 | OH | N | Behavioral Health & Social Service Providers | Counselor | Mental Health | 101YP2500X | C.1400261 | OH | N | Behavioral Health & Social Service Providers | Counselor | Professional | 101YP2500X | E1800906-SUPV | OH | Y | Behavioral Health & Social Service Providers | Counselor | Professional | 101Y00000X | C.1400261 | OH | N | Behavioral Health & Social Service Providers | Counselor |
No ID Information.