Healthcare Provider Details

I. General information

NPI: 1790294726
Provider Name (Legal Business Name): KELLYN BEESE LPCC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KELLYN WAGNER

II. Dates (important events)

Enumeration Date: 09/21/2017
Last Update Date: 10/03/2024
Certification Date: 10/03/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

23550 CENTER RIDGE RD STE 102
WESTLAKE OH
44145-3655
US

IV. Provider business mailing address

23550 CENTER RIDGE RD STE 102
WESTLAKE OH
44145-3655
US

V. Phone/Fax

Practice location:
  • Phone: 440-732-5252
  • Fax:
Mailing address:
  • Phone: 440-732-5252
  • Fax: 440-271-2003

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberE.2404762
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberC.1700505
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberC.1700505
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: