Provider Demographics
NPI:1073896445
Name:FLETCHER, KELLY (LLMSW)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:FLETCHER
Suffix:
Gender:F
Credentials:LLMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25 OWEN ST
Mailing Address - Street 2:
Mailing Address - City:BELLEVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:48111-2921
Mailing Address - Country:US
Mailing Address - Phone:734-697-7880
Mailing Address - Fax:734-697-7377
Practice Address - Street 1:25 OWEN
Practice Address - Street 2:
Practice Address - City:BELLEVILLE
Practice Address - State:MI
Practice Address - Zip Code:48111
Practice Address - Country:US
Practice Address - Phone:734-697-7880
Practice Address - Fax:734-697-7377
Is Sole Proprietor?:No
Enumeration Date:2011-09-22
Last Update Date:2011-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI680703064101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health