Healthcare Provider Details

I. General information

NPI: 1043153729
Provider Name (Legal Business Name): KELLY L HENDERSON CMS, QMHS, RA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/09/2026
Last Update Date: 06/10/2026
Certification Date: 06/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

527 N MERIDIAN RD
YOUNGSTOWN OH
44509-1227
US

IV. Provider business mailing address

527 N MERIDIAN RD
YOUNGSTOWN OH
44509-1227
US

V. Phone/Fax

Practice location:
  • Phone: 330-797-0070
  • Fax: 330-797-9146
Mailing address:
  • Phone: 330-797-0070
  • Fax: 330-797-9146

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code405300000X
TaxonomyPrevention Professional
License NumberRA.164902
License Number StateOH
# 3
Primary TaxonomyN
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: