Provider Demographics
NPI:1851790349
Name:FITZPATRICK, KELLY
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:FITZPATRICK
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 1:6158 HIGH VALLEY DR
Mailing Address - Street 2:
Mailing Address - City:WHITE LAKE
Mailing Address - State:MI
Mailing Address - Zip Code:48383-3378
Mailing Address - Country:US
Mailing Address - Phone:248-887-6292
Mailing Address - Fax:
Practice Address - Street 1:6158 HIGH VALLEY DR
Practice Address - Street 2:
Practice Address - City:WHITE LAKE
Practice Address - State:MI
Practice Address - Zip Code:48383-3378
Practice Address - Country:US
Practice Address - Phone:248-887-6292
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-20
Last Update Date:2014-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401013924101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional