Provider Demographics
NPI:1134701717
Name:KELLEY, ALIVIA CHARLENE
Entity Type:Individual
Prefix:
First Name:ALIVIA
Middle Name:CHARLENE
Last Name:KELLEY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3730 LAPEER RD LOT 35
Mailing Address - Street 2:
Mailing Address - City:PORT HURON
Mailing Address - State:MI
Mailing Address - Zip Code:48060-4503
Mailing Address - Country:US
Mailing Address - Phone:810-956-5332
Mailing Address - Fax:
Practice Address - Street 1:3104 KING RD
Practice Address - Street 2:
Practice Address - City:CHINA
Practice Address - State:MI
Practice Address - Zip Code:48054-1428
Practice Address - Country:US
Practice Address - Phone:810-285-0902
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-23
Last Update Date:2021-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician