Healthcare Provider Details

I. General information

NPI: 1033409222
Provider Name (Legal Business Name): KSK HEALTH SERVICES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/09/2011
Last Update Date: 12/12/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6929 W 130TH ST SUITE 503
PARMA HEIGHTS OH
44130-7895
US

IV. Provider business mailing address

6929 W 130TH ST SUITE 503
PARMA HEIGHTS OH
44130-7895
US

V. Phone/Fax

Practice location:
  • Phone: 440-481-3055
  • Fax: 440-481-3222
Mailing address:
  • Phone: 440-481-3055
  • Fax: 440-481-3222

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberE0004052
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberE0900389
License Number StateOH
# 3
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberE0007819
License Number StateOH
# 4
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number6890
License Number StateOH
# 5
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberI0007634
License Number StateOH
# 6
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number35099315
License Number StateOH
# 7
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number35060650
License Number StateOH
# 8
Primary TaxonomyN
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number35060650
License Number StateOH

VIII. Authorized Official

Name: STEPHANIE L KIDD
Title or Position: MANAGER/CEO
Credential: LPCC/PCC
Phone: 440-481-3055