Healthcare Provider Details

I. General information

NPI: 1871200089
Provider Name (Legal Business Name): KELLEY CHRISTINE MIRRA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/28/2022
Last Update Date: 12/12/2025
Certification Date: 12/12/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5500 S MARGINAL RD STE 110
CLEVELAND OH
44103-1009
US

IV. Provider business mailing address

1801 WATERMARK DR
COLUMBUS OH
43215-7088
US

V. Phone/Fax

Practice location:
  • Phone: 216-221-7588
  • Fax:
Mailing address:
  • Phone: 614-487-8758
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberS2202721
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: