Provider Demographics
NPI:1245699800
Name:OSTROUT, KELLY (MED, EDS)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:OSTROUT
Suffix:
Gender:F
Credentials:MED, EDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1801 SCHNEIDER ST NE
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:OH
Mailing Address - Zip Code:44721-3349
Mailing Address - Country:US
Mailing Address - Phone:330-494-0372
Mailing Address - Fax:
Practice Address - Street 1:1801 SCHNEIDER ST NE
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:OH
Practice Address - Zip Code:44721-3349
Practice Address - Country:US
Practice Address - Phone:330-494-0372
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-02-11
Last Update Date:2016-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH21198977103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH21198977Medicaid