Basic Information
| Provider Information | |||||||||
| NPI: | 1821665902 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KISH | ||||||||
| FirstName: | WESLEY | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | CDCA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6753 STATE RD | ||||||||
| Address2: | |||||||||
| City: | PARMA | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441344517 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4408435544 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3135 EUCLID AVE | ||||||||
| Address2: | |||||||||
| City: | CLEVELAND | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441152531 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2163912064 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/08/2021 | ||||||||
| LastUpdateDate: | 06/08/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/08/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | CDCA.174801 | OH | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
No ID Information.