Basic Information
| Provider Information | |||||||||
| NPI: | 1588134712 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | VALERIUS | ||||||||
| FirstName: | KATHLEEN | ||||||||
| MiddleName: | MARY | ||||||||
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| Credential: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 3445 S MAIN ST | ||||||||
| Address2: | |||||||||
| City: | COVENTRY TOWNSHIP | ||||||||
| State: | OH | ||||||||
| PostalCode: | 443193028 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3306444095 | ||||||||
| FaxNumber: | 3306452033 | ||||||||
| Practice Location | |||||||||
| Address1: | 3445 S MAIN ST | ||||||||
| Address2: | |||||||||
| City: | COVENTRY TOWNSHIP | ||||||||
| State: | OH | ||||||||
| PostalCode: | 443193028 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3306444095 | ||||||||
| FaxNumber: | 3306452033 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/30/2018 | ||||||||
| LastUpdateDate: | 04/05/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 04/05/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171M00000X | 161323 | OH | N | Other Service Providers | Case Manager/Care Coordinator | 101YA0400X | 161323 | OH | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
ID Information
| ID | Type | State | Issuer | Description | 0339770 | 05 | OH | MEDICAID |