Provider Demographics
NPI:1295850121
Name:KELLEY, ERICA M (LPC,CRC,LBSW)
Entity Type:Individual
Prefix:
First Name:ERICA
Middle Name:M
Last Name:KELLEY
Suffix:
Gender:F
Credentials:LPC,CRC,LBSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 3725
Mailing Address - Street 2:
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48037-3725
Mailing Address - Country:US
Mailing Address - Phone:313-231-7817
Mailing Address - Fax:
Practice Address - Street 1:7310 WOODWARD AVE
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48202-3165
Practice Address - Country:US
Practice Address - Phone:313-231-7817
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-20
Last Update Date:2020-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6802083850104100000X
MI6401009344101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No104100000XBehavioral Health & Social Service ProvidersSocial Worker