Provider Demographics
NPI:1902319379
Name:KELLY-LEWIS, VERONICA (BA, MSED QMHS)
Entity Type:Individual
Prefix:MS
First Name:VERONICA
Middle Name:
Last Name:KELLY-LEWIS
Suffix:
Gender:F
Credentials:BA, MSED QMHS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8532 MENTOR AVE
Mailing Address - Street 2:
Mailing Address - City:MENTOR
Mailing Address - State:OH
Mailing Address - Zip Code:44060-5822
Mailing Address - Country:US
Mailing Address - Phone:440-205-1008
Mailing Address - Fax:440-205-1047
Practice Address - Street 1:8532 MENTOR AVE
Practice Address - Street 2:
Practice Address - City:MENTOR
Practice Address - State:OH
Practice Address - Zip Code:44060-5822
Practice Address - Country:US
Practice Address - Phone:440-205-1008
Practice Address - Fax:440-205-1047
Is Sole Proprietor?:Yes
Enumeration Date:2017-11-08
Last Update Date:2018-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X
OH167140101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty
No171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Multi-Specialty