Basic Information
| Provider Information | |||||||||
| NPI: | 1821523259 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HOLDER-COBURN | ||||||||
| FirstName: | KELLY | ||||||||
| MiddleName: | |||||||||
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| Credential: | LPC, LICDC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 535 E 4TH ST | ||||||||
| Address2: | |||||||||
| City: | DELPHOS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 458331504 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4199798944 | ||||||||
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| Practice Location | |||||||||
| Address1: | 206 E MARKET ST | ||||||||
| Address2: | |||||||||
| City: | LIMA | ||||||||
| State: | OH | ||||||||
| PostalCode: | 458014914 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9373876395 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/24/2017 | ||||||||
| LastUpdateDate: | 09/29/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/29/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | C.1300431 | OH | Y | Behavioral Health & Social Service Providers | Counselor | Professional | 101YA0400X | 121121 | OH | N | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
No ID Information.