Provider Demographics
NPI:1053028720
Name:KEITH, KURTIS
Entity type:Individual
Prefix:
First Name:KURTIS
Middle Name:
Last Name:KEITH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7344 PEARL RD STE 2B
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44130-9602
Mailing Address - Country:US
Mailing Address - Phone:440-625-0081
Mailing Address - Fax:440-625-0053
Practice Address - Street 1:7344 PEARL RD STE 2B
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44130-9602
Practice Address - Country:US
Practice Address - Phone:440-625-0081
Practice Address - Fax:440-625-0053
Is Sole Proprietor?:Yes
Enumeration Date:2022-11-02
Last Update Date:2022-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHCDCA.180386101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)