Provider Demographics
NPI:1376136986
Name:MISTRY, KELLI LEE (MA LLPC)
Entity Type:Individual
Prefix:MS
First Name:KELLI
Middle Name:LEE
Last Name:MISTRY
Suffix:
Gender:F
Credentials:MA LLPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:435 LAVENDER ST
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:MI
Mailing Address - Zip Code:48162-2818
Mailing Address - Country:US
Mailing Address - Phone:734-261-6749
Mailing Address - Fax:
Practice Address - Street 1:204 S MACOMB ST STE 7
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:MI
Practice Address - Zip Code:48161-2121
Practice Address - Country:US
Practice Address - Phone:734-265-6749
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-15
Last Update Date:2022-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401019064101YM0800X
MI6451019064101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health