Healthcare Provider Details

I. General information

NPI: 1609377514
Provider Name (Legal Business Name): KELLY D EDGELL LCDCIII
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/26/2018
Last Update Date: 11/06/2025
Certification Date: 11/06/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1127 W MAIN ST
ZANESVILLE OH
43701-3147
US

IV. Provider business mailing address

1127 W MAIN ST
ZANESVILLE OH
43701-3147
US

V. Phone/Fax

Practice location:
  • Phone: 740-454-1266
  • Fax: 740-454-7650
Mailing address:
  • Phone: 740-454-1266
  • Fax: 740-454-7650

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberLCDCIII.081187
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: