Basic Information
| Provider Information | |||||||||
| NPI: | 1710214622 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FRILEY | ||||||||
| FirstName: | KIMBERLY | ||||||||
| MiddleName: | ANNE | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.ED. PCC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 625 CLEVELAND AVE NW | ||||||||
| Address2: | |||||||||
| City: | CANTON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 447021805 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3045503743 | ||||||||
| FaxNumber: | 3304536716 | ||||||||
| Practice Location | |||||||||
| Address1: | 1341 MARKET AVE N | ||||||||
| Address2: | |||||||||
| City: | CANTON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 447142605 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3304538252 | ||||||||
| FaxNumber: | 3304536716 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/13/2009 | ||||||||
| LastUpdateDate: | 04/27/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/27/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | E.0500471-SUPV | OH | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
ID Information
| ID | Type | State | Issuer | Description | 0181409 | 05 | OH | MEDICAID |