MEDICARE: KAY LORRAINE KELBLEY I.0008635-SUPV

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	104100000X	Social Worker		OH

General Provider Information

NPI Number	:	1710684014
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KAY LORRAINE KELBLEY I.0008635-SUPV

Provider Business Mailing Address
First Line	:	15 S SAINT CLAIR ST
Second Line	:
City	:	DAYTON
State	:	OH
Zip	:	45402-2143
Country	:	US
Telephone Number	:	937-684-3303
Fax Number	:	937-224-0847

Provider Business Practice Location Address
First Line	:	15 S SAINT CLAIR ST
Second Line	:
City	:	DAYTON
State	:	OH
Zip	:	45402-2143
Country	:	US
Telephone Number	:	937-684-3303
Fax Number	:	937-224-0847

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/08/2023
Last Update Date	:	02/08/2023

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