Healthcare Provider Details

I. General information

NPI: 1356853170
Provider Name (Legal Business Name): KELLYE AMANDA CROSS LISW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KELLYE AMANDA MORETTI

II. Dates (important events)

Enumeration Date: 11/02/2017
Last Update Date: 11/02/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3433 AGLER RD STE 2000
COLUMBUS OH
43219-3397
US

IV. Provider business mailing address

3433 AGLER RD STE 2000
COLUMBUS OH
43219-3397
US

V. Phone/Fax

Practice location:
  • Phone: 614-600-2708
  • Fax: 614-476-6708
Mailing address:
  • Phone: 614-600-2708
  • Fax: 614-476-6708

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberI.1700684
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: