Healthcare Provider Details

I. General information

NPI: 1992423727
Provider Name (Legal Business Name): KELLY EADES CDCA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/18/2022
Last Update Date: 08/21/2024
Certification Date: 08/21/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

302 W MAIN ST
FAIRBORN OH
45324-5037
US

IV. Provider business mailing address

100 CROWNE POINT PL
CINCINNATI OH
45241-5427
US

V. Phone/Fax

Practice location:
  • Phone: 937-281-4673
  • Fax: 937-318-1120
Mailing address:
  • Phone: 513-743-7628
  • Fax: 513-737-1107

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberCDCA.181467
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License NumberLCDCII.162034
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: