Provider Demographics
NPI:1518483189
Name:GAVIGAN, KELLEY LYNN (LMSW)
Entity Type:Individual
Prefix:
First Name:KELLEY
Middle Name:LYNN
Last Name:GAVIGAN
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6549 TOWN CENTER DR STE A
Mailing Address - Street 2:
Mailing Address - City:CLARKSTON
Mailing Address - State:MI
Mailing Address - Zip Code:48346-4824
Mailing Address - Country:US
Mailing Address - Phone:248-620-6400
Mailing Address - Fax:
Practice Address - Street 1:8150 OLD 13 MILE RD
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:MI
Practice Address - Zip Code:48093-8700
Practice Address - Country:US
Practice Address - Phone:800-395-3223
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-16
Last Update Date:2021-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68011013911041C0700X
MI68011096161041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIMI3861OtherMEDICARE
MI3382844061Medicaid