Provider Demographics
NPI:1326185711
Name:MCKELVIE, DIANE MARIE (MALLP)
Entity Type:Individual
Prefix:
First Name:DIANE
Middle Name:MARIE
Last Name:MCKELVIE
Suffix:
Gender:F
Credentials:MALLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3237 BACON AVE
Mailing Address - Street 2:
Mailing Address - City:BERKLEY
Mailing Address - State:MI
Mailing Address - Zip Code:48072-1150
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:33975 DEQUINDRE RD
Practice Address - Street 2:SUITE 5
Practice Address - City:TROY
Practice Address - State:MI
Practice Address - Zip Code:48083-4649
Practice Address - Country:US
Practice Address - Phone:248-585-3239
Practice Address - Fax:248-616-9759
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301009971101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health