MEDICARE: TERRENCE JOHN KELLEMAN LICDC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YA0400X	Addiction (Substance Use Disorder) Counselor	912985	OH

General Provider Information

NPI Number	:	1447685003
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TERRENCE JOHN KELLEMAN LICDC

Provider Business Mailing Address
First Line	:	23550 CENTER RIDGE RD
Second Line	:	SUITE 208
City	:	WESTLAKE
State	:	OH
Zip	:	44145-3655
Country	:	US
Telephone Number	:	440-356-2286
Fax Number	:	440-331-3021

Provider Business Practice Location Address
First Line	:	23550 CENTER RIDGE RD
Second Line	:	SUITE 208
City	:	WESTLAKE
State	:	OH
Zip	:	44145-3655
Country	:	US
Telephone Number	:	440-356-2286
Fax Number	:	440-331-3021

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/13/2013
Last Update Date	:	10/16/2013

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