Provider Demographics
NPI:1376750281
Name:KELLY, KIMBERLY (PHD)
Entity Type:Individual
Prefix:DR
First Name:KIMBERLY
Middle Name:
Last Name:KELLY
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3270 W BIG BEAVER RD
Mailing Address - Street 2:SUITE 400
Mailing Address - City:TROY
Mailing Address - State:MI
Mailing Address - Zip Code:48084-2901
Mailing Address - Country:US
Mailing Address - Phone:313-701-7754
Mailing Address - Fax:248-816-2801
Practice Address - Street 1:3270 W BIG BEAVER RD
Practice Address - Street 2:SUITE 400
Practice Address - City:TROY
Practice Address - State:MI
Practice Address - Zip Code:48084-2901
Practice Address - Country:US
Practice Address - Phone:313-701-7754
Practice Address - Fax:248-816-2801
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-17
Last Update Date:2012-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301012132103TC1900X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling