Provider Demographics
NPI:1881058030
Name:PALMER, KELLI REBECCA (MA, EDS)
Entity type:Individual
Prefix:MRS
First Name:KELLI
Middle Name:REBECCA
Last Name:PALMER
Suffix:
Gender:F
Credentials:MA, EDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1071 BEECHWOOD DR
Mailing Address - Street 2:
Mailing Address - City:GIRARD
Mailing Address - State:OH
Mailing Address - Zip Code:44420-2105
Mailing Address - Country:US
Mailing Address - Phone:330-402-7030
Mailing Address - Fax:
Practice Address - Street 1:6000 YOUNGSTOWN WARREN RD
Practice Address - Street 2:
Practice Address - City:NILES
Practice Address - State:OH
Practice Address - Zip Code:44446-4624
Practice Address - Country:US
Practice Address - Phone:330-505-2800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-04-13
Last Update Date:2016-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH21145306103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool