Provider Demographics
NPI:1083169601
Name:BAILEY, KELLEY
Entity Type:Individual
Prefix:
First Name:KELLEY
Middle Name:
Last Name:BAILEY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KELLEY
Other - Middle Name:
Other - Last Name:VALLENTINE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2400 SCIENCE PKWY
Mailing Address - Street 2:
Mailing Address - City:OKEMOS
Mailing Address - State:MI
Mailing Address - Zip Code:48864-5506
Mailing Address - Country:US
Mailing Address - Phone:517-374-8066
Mailing Address - Fax:517-374-5912
Practice Address - Street 1:2400 SCIENCE PKWY
Practice Address - Street 2:
Practice Address - City:OKEMOS
Practice Address - State:MI
Practice Address - Zip Code:48864-5506
Practice Address - Country:US
Practice Address - Phone:517-374-8066
Practice Address - Fax:517-374-5912
Is Sole Proprietor?:No
Enumeration Date:2016-08-24
Last Update Date:2024-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6801096082104100000X
MI7401000744103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No104100000XBehavioral Health & Social Service ProvidersSocial Worker