Provider Demographics
NPI:1598121576
Name:KELLEY, LARRY
Entity Type:Individual
Prefix:
First Name:LARRY
Middle Name:
Last Name:KELLEY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 663
Mailing Address - Street 2:
Mailing Address - City:LAKELAND
Mailing Address - State:MI
Mailing Address - Zip Code:48143-0663
Mailing Address - Country:US
Mailing Address - Phone:810-599-2129
Mailing Address - Fax:
Practice Address - Street 1:912 S WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:OWOSSO
Practice Address - State:MI
Practice Address - Zip Code:48867-4447
Practice Address - Country:US
Practice Address - Phone:989-217-8061
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-01-06
Last Update Date:2022-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI247220000XTECHNICIANOtherTAXONOMY