Healthcare Provider Details

I. General information

NPI: 1780547224
Provider Name (Legal Business Name): KELLY A DEARDOFF
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/03/2025
Last Update Date: 12/03/2025
Certification Date: 12/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

149 MERCY BLVD
MOUNT ORAB OH
45154-0296
US

IV. Provider business mailing address

149 MERCY BLVD
MOUNT ORAB OH
45154-0296
US

V. Phone/Fax

Practice location:
  • Phone: 937-712-3121
  • Fax: 937-712-3122
Mailing address:
  • Phone: 937-712-3121
  • Fax: 937-712-3122

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: