Provider Demographics
NPI:1821255423
Name:DZIEDZIC, KELLY (LLP)
Entity Type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:
Last Name:DZIEDZIC
Suffix:
Gender:F
Credentials:LLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8397 FAWN MEADOW TRL
Mailing Address - Street 2:
Mailing Address - City:GALESBURG
Mailing Address - State:MI
Mailing Address - Zip Code:49053-7745
Mailing Address - Country:US
Mailing Address - Phone:269-760-0660
Mailing Address - Fax:
Practice Address - Street 1:8397 FAWN MEADOW TRL
Practice Address - Street 2:
Practice Address - City:GALESBURG
Practice Address - State:MI
Practice Address - Zip Code:49053-7745
Practice Address - Country:US
Practice Address - Phone:269-760-0660
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-21
Last Update Date:2024-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6361004240103T00000X, 103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty
No103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounselingGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1708146Medicaid