Healthcare Provider Details

I. General information

NPI: 1700373586
Provider Name (Legal Business Name): KELLY KENNARD LPC, MFT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/17/2018
Last Update Date: 02/20/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1680 NAVE RD SE
MASSILLON OH
44646
US

IV. Provider business mailing address

625 CLEVELAND AVE NW
CANTON OH
44702-1805
US

V. Phone/Fax

Practice location:
  • Phone: 330-830-8740
  • Fax: 330-830-0912
Mailing address:
  • Phone: 330-455-0374
  • Fax: 330-453-6716

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberC1801257
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberM.1800071
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: