Healthcare Provider Details

I. General information

NPI: 1346753340
Provider Name (Legal Business Name): KELSEY ANNE MARSHALL LISW-S, LCDC III
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/13/2017
Last Update Date: 04/24/2026
Certification Date: 04/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

54 S STATE ST
PAINESVILLE OH
44077-3445
US

IV. Provider business mailing address

7232 JUSTIN WAY
MENTOR OH
44060-4881
US

V. Phone/Fax

Practice location:
  • Phone: 440-578-8200
  • Fax:
Mailing address:
  • Phone: 440-578-8200
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberLCDCIII.162051
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberI.2405358-SUPV
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: