Healthcare Provider Details

I. General information

NPI: 1205771508
Provider Name (Legal Business Name): MARY ELLEN KAUCHECK PSY.S.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/22/2026
Last Update Date: 04/22/2026
Certification Date: 04/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

528 GARFORD AVE
ELYRIA OH
44035-6410
US

IV. Provider business mailing address

27652 REMINGTON DR
WESTLAKE OH
44145-2164
US

V. Phone/Fax

Practice location:
  • Phone: 440-284-8011
  • Fax:
Mailing address:
  • Phone: 440-284-8071
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License NumberLSP.00680
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: