1770082018 NPI number — AMY DANIELLE KELLY LPC, QMHP

Table of content: AMY DANIELLE KELLY LPC, QMHP (NPI 1770082018)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1770082018 NPI number — AMY DANIELLE KELLY LPC, QMHP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KELLY
Provider First Name:
AMY
Provider Middle Name:
DANIELLE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LPC, QMHP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
PALMER
Provider Other First Name:
AMY
Provider Other Middle Name:
DANIELLE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1770082018
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/19/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
11667 CHAREST ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HAMTRAMCK
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48212-3026
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
313-442-6272
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
323 N STATE ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CARO
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48723-1537
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
989-673-6191
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
02/01/2018

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 171M00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)