Provider Demographics
NPI:1740744648
Name:NEELY, KYLE DOUGLAS (LLMSW)
Entity Type:Individual
Prefix:
First Name:KYLE
Middle Name:DOUGLAS
Last Name:NEELY
Suffix:
Gender:M
Credentials:LLMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:398 N SHELDON RD
Mailing Address - Street 2:
Mailing Address - City:PLYMOUTH
Mailing Address - State:MI
Mailing Address - Zip Code:48170-1032
Mailing Address - Country:US
Mailing Address - Phone:734-355-3010
Mailing Address - Fax:
Practice Address - Street 1:575 S MAIN ST STE 6
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:MI
Practice Address - Zip Code:48170-1778
Practice Address - Country:US
Practice Address - Phone:734-451-7800
Practice Address - Fax:734-451-5410
Is Sole Proprietor?:No
Enumeration Date:2019-01-24
Last Update Date:2019-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6801102999104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker