Healthcare Provider Details

I. General information

NPI: 1790335487
Provider Name (Legal Business Name): KELLY WUENNEMANN QMHS BA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/16/2019
Last Update Date: 05/20/2025
Certification Date: 05/20/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1501 MADISON RD
WALNUT HILLS OH
45206-1706
US

IV. Provider business mailing address

1501 MADISON RD
WALNUT HILLS OH
45206-1706
US

V. Phone/Fax

Practice location:
  • Phone: 513-354-5200
  • Fax:
Mailing address:
  • Phone: 513-354-5200
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License NumberS.2403399-TRNE
License Number StateOH
# 3
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberS.2512196
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: