Basic Information
| Provider Information | |||||||||
| NPI: | 1689731960 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KELLY | ||||||||
| FirstName: | JAMES | ||||||||
| MiddleName: | FREDRIC | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | LPC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 707 W MILWAUKEE ST | ||||||||
| Address2: | 7TH FLOOR | ||||||||
| City: | DETROIT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 482022943 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3133449099 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 707 W MILWAUKEE ST | ||||||||
| Address2: | 7TH FLOOR | ||||||||
| City: | DETROIT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 482022943 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3133449099 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/03/2007 | ||||||||
| LastUpdateDate: | 06/27/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | 6401006271 | MI | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
No ID Information.