Basic Information
| Provider Information | |||||||||
| NPI: | 1487046793 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | KELLY THOMAS LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2193 ASSOCIATION DR STE 100 | ||||||||
| Address2: | |||||||||
| City: | OKEMOS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 488644904 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5173165239 | ||||||||
| FaxNumber: | 5173493755 | ||||||||
| Practice Location | |||||||||
| Address1: | 2193 ASSOCIATION DR STE 100 | ||||||||
| Address2: | |||||||||
| City: | OKEMOS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 488644904 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5173165239 | ||||||||
| FaxNumber: | 5173493755 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/23/2015 | ||||||||
| LastUpdateDate: | 02/20/2019 | ||||||||
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| AuthorizedOfficialLastName: | THOMAS | ||||||||
| AuthorizedOfficialFirstName: | KELLY | ||||||||
| AuthorizedOfficialMiddleName: | LEIGH | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 5173165239 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 6801090422 | MI | Y | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.