1699928416 NPI number — MS. KELLY CATHLEEN KELLY-ZAZADO LCSW/ACSW

Table of content: MS. KELLY CATHLEEN KELLY-ZAZADO LCSW/ACSW (NPI 1699928416)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1699928416 NPI number — MS. KELLY CATHLEEN KELLY-ZAZADO LCSW/ACSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KELLY-ZAZADO
Provider First Name:
KELLY
Provider Middle Name:
CATHLEEN
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
LCSW/ACSW
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1699928416
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/23/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
301 W. 10TH ST., LAKE ERIE COUNSELING, INC
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ERIE
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
16502
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
814-455-4009
Provider Business Mailing Address Fax Number:
814-455-7715

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
301 W. 10TH ST., LAKE ERIE COUNSELING, INC
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ERIE
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
16502
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
814-455-4009
Provider Business Practice Location Address Fax Number:
814-455-7715
Provider Enumeration Date:
10/23/2008

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X , with the licence number:  C006963 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 1041C0700X , with the licence number: CW016702 , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 102774194 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".