Provider Demographics
NPI:1356813539
Name:KOVACH-COLLICOTT, KELLY MICHELLE (LMSW, ACSW)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:MICHELLE
Last Name:KOVACH-COLLICOTT
Suffix:
Gender:F
Credentials:LMSW, ACSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14100 NEWBURGH RD
Mailing Address - Street 2:
Mailing Address - City:LIVONIA
Mailing Address - State:MI
Mailing Address - Zip Code:48154-5010
Mailing Address - Country:US
Mailing Address - Phone:734-464-7810
Mailing Address - Fax:
Practice Address - Street 1:14100 NEWBURGH RD
Practice Address - Street 2:
Practice Address - City:LIVONIA
Practice Address - State:MI
Practice Address - Zip Code:48154-5010
Practice Address - Country:US
Practice Address - Phone:734-464-7810
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-12-27
Last Update Date:2018-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010930311041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical