Provider Demographics
NPI:1972046837
Name:CHARETTE, KELLY (LLMSW)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:CHARETTE
Suffix:
Gender:F
Credentials:LLMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4550 MEDLER DR
Mailing Address - Street 2:
Mailing Address - City:MORLEY
Mailing Address - State:MI
Mailing Address - Zip Code:49336-9173
Mailing Address - Country:US
Mailing Address - Phone:231-388-3204
Mailing Address - Fax:
Practice Address - Street 1:4550 MEDLER DR
Practice Address - Street 2:
Practice Address - City:MORLEY
Practice Address - State:MI
Practice Address - Zip Code:49336-9173
Practice Address - Country:US
Practice Address - Phone:231-388-3204
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-11-28
Last Update Date:2024-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
175T00000X
MI68511101651041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No175T00000XOther Service ProvidersPeer SpecialistGroup - Multi-Specialty