Provider Demographics
NPI:1053826933
Name:QUINN, KELLY ANNE (MA, LPC)
Entity Type:Individual
Prefix:MS
First Name:KELLY
Middle Name:ANNE
Last Name:QUINN
Suffix:
Gender:F
Credentials:MA, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1333 BREWERY PARK BLVD STE 140
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48207-4544
Mailing Address - Country:US
Mailing Address - Phone:313-576-2513
Mailing Address - Fax:313-576-2501
Practice Address - Street 1:1333 BREWERY PARK BLVD STE 140
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48207-4544
Practice Address - Country:US
Practice Address - Phone:313-576-2513
Practice Address - Fax:313-576-2501
Is Sole Proprietor?:No
Enumeration Date:2017-12-13
Last Update Date:2017-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401008081101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI6401008081OtherLICENSED PROFESSIONAL COUNSELOR