Provider Demographics
NPI:1598976375
Name:DISTELRATH, KELLY D (LLP)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:D
Last Name:DISTELRATH
Suffix:
Gender:F
Credentials:LLP
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:D
Other - Last Name:HADDEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1340 PINECREST DR
Mailing Address - Street 2:
Mailing Address - City:FERNDALE
Mailing Address - State:MI
Mailing Address - Zip Code:48220-1608
Mailing Address - Country:US
Mailing Address - Phone:586-258-0206
Mailing Address - Fax:586-258-0201
Practice Address - Street 1:520 SUPERIOR ST
Practice Address - Street 2:
Practice Address - City:PORT HURON
Practice Address - State:MI
Practice Address - Zip Code:48060-3838
Practice Address - Country:US
Practice Address - Phone:810-984-4202
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-24
Last Update Date:2021-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
MI6361007549103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health