Provider Demographics
NPI:1366860470
Name:TERVOL, KELLY
Entity Type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:
Last Name:TERVOL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6692 SPRING ARBOR RD
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MI
Mailing Address - Zip Code:49201-9322
Mailing Address - Country:US
Mailing Address - Phone:517-750-3869
Mailing Address - Fax:
Practice Address - Street 1:6692 SPRING ARBOR RD
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MI
Practice Address - Zip Code:49201-9322
Practice Address - Country:US
Practice Address - Phone:517-750-3869
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-04-04
Last Update Date:2014-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401013548101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health