Provider Demographics
NPI:1023363488
Name:BASSHAM, KELLY MICHAEL (LMSW)
Entity Type:Individual
Prefix:MR
First Name:KELLY
Middle Name:MICHAEL
Last Name:BASSHAM
Suffix:
Gender:M
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 ELM ST STE 200D
Mailing Address - Street 2:
Mailing Address - City:BIRMINGHAM
Mailing Address - State:MI
Mailing Address - Zip Code:48009-6322
Mailing Address - Country:US
Mailing Address - Phone:248-986-2991
Mailing Address - Fax:248-294-1237
Practice Address - Street 1:200 ELM ST STE 200D
Practice Address - Street 2:
Practice Address - City:BIRMINGHAM
Practice Address - State:MI
Practice Address - Zip Code:48009-6322
Practice Address - Country:US
Practice Address - Phone:248-986-2991
Practice Address - Fax:248-294-1237
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-20
Last Update Date:2021-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010909081041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical