Basic Information
| Provider Information | |||||||||
| NPI: | 1093871717 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KELLY | ||||||||
| FirstName: | JOSEPH | ||||||||
| MiddleName: | B | ||||||||
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| Credential: | LPC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 45 | ||||||||
| Address2: | |||||||||
| City: | PORTAGE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 463680045 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2197871510 | ||||||||
| FaxNumber: | 2197878761 | ||||||||
| Practice Location | |||||||||
| Address1: | 3600 VETERANS DR | ||||||||
| Address2: | SUITE 3 | ||||||||
| City: | TRAVERSE CITY | ||||||||
| State: | MI | ||||||||
| PostalCode: | 496844582 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2319334009 | ||||||||
| FaxNumber: | 2319334032 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/28/2006 | ||||||||
| LastUpdateDate: | 06/09/2009 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101Y00000X | 6401005316 | MI | Y | Behavioral Health & Social Service Providers | Counselor |
No ID Information.