Basic Information
Provider Information | |||||||||
NPI: | 1447875547 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | GILL | ||||||||
FirstName: | KELSEY | ||||||||
MiddleName: | LEIGH | ||||||||
NamePrefix: | MRS. | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 7155 OLIVESBURG FITCHVILLE RD | ||||||||
Address2: |   | ||||||||
City: | GREENWICH | ||||||||
State: | OH | ||||||||
PostalCode: | 448379603 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4194963345 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 2775 STATE ROUTE 39 | ||||||||
Address2: |   | ||||||||
City: | SHELBY | ||||||||
State: | OH | ||||||||
PostalCode: | 448759466 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4197473322 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/15/2020 | ||||||||
LastUpdateDate: | 11/03/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 11/03/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | CDCA.182472 | OH | Y |   | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 171M00000X |   |   | N |   | Other Service Providers | Case Manager/Care Coordinator |   |
ID Information
ID | Type | State | Issuer | Description | 0406830 | 05 | OH |   | MEDICAID |