Provider Demographics
NPI:1447588363
Name:MICHAUD, KELLY M (LPC)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:M
Last Name:MICHAUD
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:A
Other - Last Name:MURPHY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LPC
Mailing Address - Street 1:7306 GA HWY 21
Mailing Address - Street 2:SUITE 101, BOX 224
Mailing Address - City:PORT WENTWORTH
Mailing Address - State:GA
Mailing Address - Zip Code:31407-9275
Mailing Address - Country:US
Mailing Address - Phone:912-508-1223
Mailing Address - Fax:912-257-4413
Practice Address - Street 1:128 FRANCES MEEKS WAY STE 16
Practice Address - Street 2:
Practice Address - City:RICHMOND HILL
Practice Address - State:GA
Practice Address - Zip Code:31324-3985
Practice Address - Country:US
Practice Address - Phone:912-508-1223
Practice Address - Fax:912-257-4413
Is Sole Proprietor?:Yes
Enumeration Date:2009-12-04
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPC007469101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA12610067OtherCAQH
GA003141299AMedicaid