Provider Demographics
NPI:1023055936
Name:TEAGUE, KELLY A (LISW)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:A
Last Name:TEAGUE
Suffix:
Gender:F
Credentials:LISW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8006 CRESCENT DR
Mailing Address - Street 2:
Mailing Address - City:CLARKSTON
Mailing Address - State:MI
Mailing Address - Zip Code:48348-3939
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6637 HIGHLAND RD
Practice Address - Street 2:
Practice Address - City:WATERFORD
Practice Address - State:MI
Practice Address - Zip Code:48327-1675
Practice Address - Country:US
Practice Address - Phone:248-666-8870
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-31
Last Update Date:2007-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010770261041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical