Healthcare Provider Details

I. General information

NPI: 1053236349
Provider Name (Legal Business Name): KERRIS MONCREACE
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/13/2026
Last Update Date: 08/13/2026
Certification Date: 08/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1591 MOOBERRY ST
COLUMBUS OH
43205-2939
US

IV. Provider business mailing address

1591 MOOBERRY ST
COLUMBUS OH
43205-2939
US

V. Phone/Fax

Practice location:
  • Phone: 614-649-9537
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TB0200X
TaxonomyCognitive & Behavioral Psychologist
License NumberUD534346
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: