Provider Demographics
NPI:1053429605
Name:DAWSON, KELLIE JEAN (LISW-S)
Entity type:Individual
Prefix:
First Name:KELLIE
Middle Name:JEAN
Last Name:DAWSON
Suffix:
Gender:F
Credentials:LISW-S
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:163 N SANDUSKY ST STE 104
Mailing Address - Street 2:
Mailing Address - City:DELAWARE
Mailing Address - State:OH
Mailing Address - Zip Code:43015-1778
Mailing Address - Country:US
Mailing Address - Phone:614-946-7571
Mailing Address - Fax:740-879-2826
Practice Address - Street 1:163 N SANDUSKY ST STE 104
Practice Address - Street 2:
Practice Address - City:DELAWARE
Practice Address - State:OH
Practice Address - Zip Code:43015-1778
Practice Address - Country:US
Practice Address - Phone:614-946-7571
Practice Address - Fax:740-879-2826
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-25
Last Update Date:2022-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHI. 0009062 SUPV1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH1760741110Medicare PIN