Provider Demographics
NPI:1447075502
Name:SHADE, KALI (CPRS)
Entity type:Individual
Prefix:
First Name:KALI
Middle Name:
Last Name:SHADE
Suffix:
Gender:F
Credentials:CPRS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 212
Mailing Address - Street 2:
Mailing Address - City:XENIA
Mailing Address - State:OH
Mailing Address - Zip Code:45385-0212
Mailing Address - Country:US
Mailing Address - Phone:937-505-3400
Mailing Address - Fax:937-660-5656
Practice Address - Street 1:282 STELTON RD
Practice Address - Street 2:
Practice Address - City:XENIA
Practice Address - State:OH
Practice Address - Zip Code:45385-5220
Practice Address - Country:US
Practice Address - Phone:937-505-3400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-11-22
Last Update Date:2024-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHAPS.005258175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist