Basic Information
| Provider Information | |||||||||
| NPI: | 1841780905 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ADKINS | ||||||||
| FirstName: | KELLI | ||||||||
| MiddleName: | ANN | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | CDCA, QMHS | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | HAMILTON | ||||||||
| OtherFirstName: | KELLI | ||||||||
| OtherMiddleName: | ANN | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | CDCA | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 49 TOWNSHIP ROAD 365 | ||||||||
| Address2: | |||||||||
| City: | SOUTH POINT | ||||||||
| State: | OH | ||||||||
| PostalCode: | 456809409 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7404510221 | ||||||||
| FaxNumber: | 7404510771 | ||||||||
| Practice Location | |||||||||
| Address1: | 49 TOWNSHIP ROAD 365 | ||||||||
| Address2: | |||||||||
| City: | SOUTH POINT | ||||||||
| State: | OH | ||||||||
| PostalCode: | 456809409 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7404510221 | ||||||||
| FaxNumber: | 7404510771 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/15/2018 | ||||||||
| LastUpdateDate: | 06/05/2019 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171M00000X | CDCA.165792 | OH | N | Other Service Providers | Case Manager/Care Coordinator | 101YA0400X | CDCA.165792 | OH | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
ID Information
| ID | Type | State | Issuer | Description | 0299747 | 05 | OH | MEDICAID |