Provider Demographics
NPI:1871020388
Name:ROSS-HOPKINS, KELLEY KAYE (LCDCIII)
Entity type:Individual
Prefix:
First Name:KELLEY
Middle Name:KAYE
Last Name:ROSS-HOPKINS
Suffix:
Gender:F
Credentials:LCDCIII
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1182 MOUNT VERNON AVE
Mailing Address - Street 2:
Mailing Address - City:AKRON
Mailing Address - State:OH
Mailing Address - Zip Code:44310-1104
Mailing Address - Country:US
Mailing Address - Phone:330-256-8847
Mailing Address - Fax:
Practice Address - Street 1:3600 W MARKET ST
Practice Address - Street 2:
Practice Address - City:FAIRLAWN
Practice Address - State:OH
Practice Address - Zip Code:44333-4540
Practice Address - Country:US
Practice Address - Phone:330-436-0956
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-05-15
Last Update Date:2024-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHAPS.005267175T00000X
OHLCDCIII.121033101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No175T00000XOther Service ProvidersPeer SpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0438532Medicaid