Provider Demographics
NPI:1275020695
Name:MERRILL, KELLY ANN (BSW, DP)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:ANN
Last Name:MERRILL
Suffix:
Gender:F
Credentials:BSW, DP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:529 MARTIN LUTHER KING BLVD
Mailing Address - Street 2:
Mailing Address - City:FLINT
Mailing Address - State:MI
Mailing Address - Zip Code:48502-2002
Mailing Address - Country:US
Mailing Address - Phone:810-238-7226
Mailing Address - Fax:810-239-5518
Practice Address - Street 1:529 MARTIN LUTHER KING BLVD
Practice Address - Street 2:
Practice Address - City:FLINT
Practice Address - State:MI
Practice Address - Zip Code:48502-2002
Practice Address - Country:US
Practice Address - Phone:810-238-7226
Practice Address - Fax:810-239-5518
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-20
Last Update Date:2018-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI1841325772101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)