Provider Demographics
NPI:1558718171
Name:KELLY, BRADLEY (LLPC)
Entity Type:Individual
Prefix:
First Name:BRADLEY
Middle Name:
Last Name:KELLY
Suffix:
Gender:M
Credentials:LLPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:340 WESTBROOK CT
Mailing Address - Street 2:
Mailing Address - City:MARSHALL
Mailing Address - State:MI
Mailing Address - Zip Code:49068-3121
Mailing Address - Country:US
Mailing Address - Phone:269-910-4606
Mailing Address - Fax:
Practice Address - Street 1:340 WESTBROOK CT
Practice Address - Street 2:
Practice Address - City:MARSHALL
Practice Address - State:MI
Practice Address - Zip Code:49068-3121
Practice Address - Country:US
Practice Address - Phone:269-910-4606
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-24
Last Update Date:2016-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401015063101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional