MEDICARE: KELLY REEVES MEMORIAL FOUNDATION

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YP2500X	Professional Counselor

General Provider Information

NPI Number	:	1295220986
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KELLY REEVES MEMORIAL FOUNDATION

Provider Business Mailing Address
First Line	:	135 E ERIE ST STE 302
Second Line	:
City	:	KENT
State	:	OH
Zip	:	44240-3594
Country	:	US
Telephone Number	:	330-593-5959
Fax Number	:

Provider Business Practice Location Address
First Line	:	135 E ERIE ST STE 302
Second Line	:
City	:	KENT
State	:	OH
Zip	:	44240-3594
Country	:	US
Telephone Number	:	330-593-5959
Fax Number	:

Authorized Official
Title or Position	:	COUNSELOR
Name	:	PHYLLIS A VAIR
Credential	:	LPC
Telephone Number	:	330-593-5959

Provider Enumeration Date	:	06/26/2018
Last Update Date	:	02/14/2020

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