Provider Demographics
NPI:1437914413
Name:KELLEY, MCKENNA (CTRS)
Entity type:Individual
Prefix:
First Name:MCKENNA
Middle Name:
Last Name:KELLEY
Suffix:
Gender:F
Credentials:CTRS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1025 E KEARSLEY ST
Mailing Address - Street 2:
Mailing Address - City:FLINT
Mailing Address - State:MI
Mailing Address - Zip Code:48503-1997
Mailing Address - Country:US
Mailing Address - Phone:989-323-9333
Mailing Address - Fax:
Practice Address - Street 1:805 S LINE ST
Practice Address - Street 2:
Practice Address - City:CHESANING
Practice Address - State:MI
Practice Address - Zip Code:48616-1437
Practice Address - Country:US
Practice Address - Phone:989-323-9333
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-02-19
Last Update Date:2025-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X
MI86171225800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225800000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRecreation Therapist
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician