Healthcare Provider Details

I. General information

NPI: 1265213334
Provider Name (Legal Business Name): KELSY VAUGHAN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/13/2023
Last Update Date: 09/18/2024
Certification Date: 09/18/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

452 W MARKET ST
XENIA OH
45385-2815
US

IV. Provider business mailing address

3170 W CENTRAL AVE STE B
TOLEDO OH
43606-2945
US

V. Phone/Fax

Practice location:
  • Phone: 937-376-8700
  • Fax: 937-376-8725
Mailing address:
  • Phone: 567-316-7253
  • Fax: 567-316-7232

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberCDCA186050
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: