=====================================================
General NPI Number Information
=====================================================
NPI Number | 1508424797
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | HALLE KISH LPC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/03/2019
-----------------------------------------------------
Last Update Date | 05/20/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2173 N RIDGE RD E STE E
-----------------------------------------------------
City | LORAIN
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44055-3400
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 440-260-8300
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 434 EASTLAND RD
-----------------------------------------------------
City | BEREA
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44017-1217
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 440-234-2006
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101Y00000X
-----------------------------------------------------
Taxonomy Name | Counselor
-----------------------------------------------------
License Number | C.1901636-TRNE
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number | C.2002634
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------