Provider Demographics
NPI:1447685003
Name:KELLEMAN, TERRENCE JOHN (LICDC)
Entity type:Individual
Prefix:
First Name:TERRENCE
Middle Name:JOHN
Last Name:KELLEMAN
Suffix:
Gender:M
Credentials:LICDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23550 CENTER RIDGE RD
Mailing Address - Street 2:SUITE 208
Mailing Address - City:WESTLAKE
Mailing Address - State:OH
Mailing Address - Zip Code:44145-3655
Mailing Address - Country:US
Mailing Address - Phone:440-356-2286
Mailing Address - Fax:440-331-3021
Practice Address - Street 1:23550 CENTER RIDGE RD
Practice Address - Street 2:SUITE 208
Practice Address - City:WESTLAKE
Practice Address - State:OH
Practice Address - Zip Code:44145-3655
Practice Address - Country:US
Practice Address - Phone:440-356-2286
Practice Address - Fax:440-331-3021
Is Sole Proprietor?:Yes
Enumeration Date:2013-09-13
Last Update Date:2013-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH912985101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)