Basic Information
| Provider Information | |||||||||
| NPI: | 1922178631 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BILLINGSLEY | ||||||||
| FirstName: | KATHLEEN | ||||||||
| MiddleName: | |||||||||
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| Credential: | PHD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 80690 | ||||||||
| Address2: | |||||||||
| City: | CANTON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 44708 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3308335530 | ||||||||
| FaxNumber: | 3308336085 | ||||||||
| Practice Location | |||||||||
| Address1: | 3722 WHIPPLE AVE NW | ||||||||
| Address2: | |||||||||
| City: | CANTON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 44718 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3304922006 | ||||||||
| FaxNumber: | 3304922161 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/09/2006 | ||||||||
| LastUpdateDate: | 07/22/2008 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103T00000X | 5598 | OH | Y | Behavioral Health & Social Service Providers | Psychologist |
ID Information
| ID | Type | State | Issuer | Description | 2245654 | 05 | OH | MEDICAID |