Healthcare Provider Details

I. General information

NPI: 1275319659
Provider Name (Legal Business Name): KELSEY ANNE SPENCER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/01/2023
Last Update Date: 10/06/2026
Certification Date: 10/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22001 FAIRMOUNT BLVD
SHAKER HEIGHTS OH
44118-4819
US

IV. Provider business mailing address

202 E BAGLEY RD
BEREA OH
44017-2058
US

V. Phone/Fax

Practice location:
  • Phone: 216-932-2800
  • Fax:
Mailing address:
  • Phone: 440-260-6868
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License NumberC.2608181-TRNE
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: