Provider Demographics
NPI:1023773298
Name:KELP, HALEY M
Entity type:Individual
Prefix:
First Name:HALEY
Middle Name:M
Last Name:KELP
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:HALEY
Other - Middle Name:M
Other - Last Name:WELLS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3245 KEEWAHDIN RD
Mailing Address - Street 2:
Mailing Address - City:FORT GRATIOT TWP
Mailing Address - State:MI
Mailing Address - Zip Code:48059
Mailing Address - Country:US
Mailing Address - Phone:810-937-2345
Mailing Address - Fax:
Practice Address - Street 1:3245 KEEWAHDIN RD
Practice Address - Street 2:
Practice Address - City:FORT GRATIOT TWP
Practice Address - State:MI
Practice Address - Zip Code:48059
Practice Address - Country:US
Practice Address - Phone:810-937-2345
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-11-03
Last Update Date:2021-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X
MI106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician