Healthcare Provider Details

I. General information

NPI: 1821523259
Provider Name (Legal Business Name): KELLY HOLDER-COBURN LPC, LICDC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/24/2017
Last Update Date: 09/29/2021
Certification Date: 09/29/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

206 E MARKET ST
LIMA OH
45801-4914
US

IV. Provider business mailing address

535 E 4TH ST
DELPHOS OH
45833-1504
US

V. Phone/Fax

Practice location:
  • Phone: 937-387-6395
  • Fax:
Mailing address:
  • Phone: 419-979-8944
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number121121
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberC.1300431
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: