Healthcare Provider Details

I. General information

NPI: 1467012690
Provider Name (Legal Business Name): KYLE POLING CDCA QMHS BA CMS BA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/19/2019
Last Update Date: 01/08/2020
Certification Date: 01/08/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

195 N GRANT AVE STE 250
COLUMBUS OH
43215-2855
US

IV. Provider business mailing address

434 EASTLAND RD
BEREA OH
44017-1217
US

V. Phone/Fax

Practice location:
  • Phone: 440-260-8300
  • Fax:
Mailing address:
  • Phone: 440-236-2006
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberCDCA171334
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: