Healthcare Provider Details

I. General information

NPI: 1699428276
Provider Name (Legal Business Name): MARANDA KELLERMAN CDCA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/02/2022
Last Update Date: 02/02/2022
Certification Date: 02/02/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3621 ROSSGATE CT
HAMILTON OH
45013-9558
US

IV. Provider business mailing address

3621 ROSSGATE CT
HAMILTON OH
45013-9558
US

V. Phone/Fax

Practice location:
  • Phone: 513-738-7600
  • Fax: 513-738-7601
Mailing address:
  • Phone: 513-738-7600
  • Fax: 513-738-7601

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberCDCA.177754
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: