Provider Demographics
NPI:1265690267
Name:MCKELTON, GENEVA ALLEN (MSW)
Entity Type:Individual
Prefix:
First Name:GENEVA
Middle Name:ALLEN
Last Name:MCKELTON
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15801 W MCNICHOLS RD
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48235-3543
Mailing Address - Country:US
Mailing Address - Phone:313-272-8450
Mailing Address - Fax:
Practice Address - Street 1:15801 W MCNICHOLS RD
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48235-3543
Practice Address - Country:US
Practice Address - Phone:313-272-8450
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-05-27
Last Update Date:2008-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6801072558104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5255236Medicaid
MI651245437OtherCOMMERCIAL