Basic Information
| Provider Information | |||||||||
| NPI: | 1356436208 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KAIKKONEN | ||||||||
| FirstName: | KELLY | ||||||||
| MiddleName: | M. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 772263 | ||||||||
| Address2: | |||||||||
| City: | DETROIT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 482772263 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8104410045 | ||||||||
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| Practice Location | |||||||||
| Address1: | 8245 HOLLY RD STE 200 | ||||||||
| Address2: | |||||||||
| City: | GRAND BLANC | ||||||||
| State: | MI | ||||||||
| PostalCode: | 484392483 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8006931916 | ||||||||
| FaxNumber: | 2486053525 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/04/2006 | ||||||||
| LastUpdateDate: | 08/17/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/17/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101Y00000X | 6401006044 | MI | Y | Behavioral Health & Social Service Providers | Counselor | 103TC0700X | 6301009779 | MI | N | Behavioral Health & Social Service Providers | Psychologist | Clinical |
No ID Information.