Provider Demographics
NPI:1023722394
Name:KELLY, EMMA FAY (MA)
Entity type:Individual
Prefix:
First Name:EMMA
Middle Name:FAY
Last Name:KELLY
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1603 CATALPA DR
Mailing Address - Street 2:
Mailing Address - City:ROYAL OAK
Mailing Address - State:MI
Mailing Address - Zip Code:48067-1153
Mailing Address - Country:US
Mailing Address - Phone:248-912-8191
Mailing Address - Fax:
Practice Address - Street 1:7035 ORCHARD LAKE RD STE 800
Practice Address - Street 2:
Practice Address - City:WEST BLOOMFIELD
Practice Address - State:MI
Practice Address - Zip Code:48322-5301
Practice Address - Country:US
Practice Address - Phone:248-669-9500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-10
Last Update Date:2023-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6362009699103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling