Provider Demographics
NPI:1811219272
Name:NIERGARTH, KELLY
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:NIERGARTH
Suffix:
Gender:F
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 68
Mailing Address - Street 2:
Mailing Address - City:LAMONT
Mailing Address - State:MI
Mailing Address - Zip Code:49430-0068
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5816 W US HIGHWAY 10
Practice Address - Street 2:SUITE C
Practice Address - City:LUDINGTON
Practice Address - State:MI
Practice Address - Zip Code:49431-2450
Practice Address - Country:US
Practice Address - Phone:231-843-4899
Practice Address - Fax:231-843-8929
Is Sole Proprietor?:No
Enumeration Date:2010-02-25
Last Update Date:2010-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301014326103TC0700X, 104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker