Basic Information
| Provider Information | |||||||||
| NPI: | 1356698146 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KREGER | ||||||||
| FirstName: | KELLY | ||||||||
| MiddleName: | JANE | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | LMSW | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 3694 CLARKSTON RD | ||||||||
| Address2: | SUITE D | ||||||||
| City: | CLARKSTON | ||||||||
| State: | MI | ||||||||
| PostalCode: | 483485213 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2486938880 | ||||||||
| FaxNumber: | 2483917478 | ||||||||
| Practice Location | |||||||||
| Address1: | 1785 W STADIUM BLVD | ||||||||
| Address2: | SUITE 203C | ||||||||
| City: | ANN ARBOR | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481035285 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7349131093 | ||||||||
| FaxNumber: | 7344543570 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/10/2012 | ||||||||
| LastUpdateDate: | 08/10/2012 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 6801090445 | MI | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.