Basic Information
Provider Information | |||||||||
NPI: | 1215302872 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | KELLY | ||||||||
FirstName: | PATRICIA | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | LLMSW | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 3181 SANDHILL RD | ||||||||
Address2: |   | ||||||||
City: | MASON | ||||||||
State: | MI | ||||||||
PostalCode: | 488549425 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9418226248 | ||||||||
FaxNumber: | 5173366050 | ||||||||
Practice Location | |||||||||
Address1: | 421 COMMERCIAL CT STE B | ||||||||
Address2: |   | ||||||||
City: | VENICE | ||||||||
State: | FL | ||||||||
PostalCode: | 34292 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9412444377 | ||||||||
FaxNumber: | 9412444376 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/08/2015 | ||||||||
LastUpdateDate: | 02/11/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 02/11/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 6801100817 | MI | N |   | Behavioral Health & Social Service Providers | Social Worker | Clinical | 164W00000X | 4703117696 | MI | N |   | Nursing Service Providers | Licensed Practical Nurse |   | 1041C0700X | SW15678 | FL | Y |   | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.