Provider Demographics
NPI:1659305860
Name:KELATESS PC
Entity Type:Organization
Organization Name:KELATESS PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:P
Authorized Official - Last Name:DICKSON
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:810-606-1099
Mailing Address - Street 1:7382 MOHANSIC DR
Mailing Address - Street 2:
Mailing Address - City:BLOOMFIELD HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48301-3552
Mailing Address - Country:US
Mailing Address - Phone:810-606-1099
Mailing Address - Fax:
Practice Address - Street 1:1441 E MAPLE AVE
Practice Address - Street 2:
Practice Address - City:BURTON
Practice Address - State:MI
Practice Address - Zip Code:48529-2059
Practice Address - Country:US
Practice Address - Phone:810-820-6265
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-11
Last Update Date:2016-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301006835103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI680F33159OtherBLUE CROSS
MIN94310001Medicare ID - Type Unspecified
MIN93620001Medicare ID - Type Unspecified