Provider Demographics
NPI:1265150767
Name:KELLY OTP LLC
Entity type:Organization
Organization Name:KELLY OTP LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRATICE ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:AARON
Authorized Official - Middle Name:DOUGLAS
Authorized Official - Last Name:ALSTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:248-971-0150
Mailing Address - Street 1:7 RIVERBANK DR
Mailing Address - Street 2:
Mailing Address - City:BEVERLY HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48025-4800
Mailing Address - Country:US
Mailing Address - Phone:248-971-0150
Mailing Address - Fax:
Practice Address - Street 1:25200 KELLY RD
Practice Address - Street 2:
Practice Address - City:ROSEVILLE
Practice Address - State:MI
Practice Address - Zip Code:48066-4473
Practice Address - Country:US
Practice Address - Phone:586-422-1250
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-08-19
Last Update Date:2023-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM2800XAmbulatory Health Care FacilitiesClinic/CenterMethadone
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounselingGroup - Multi-Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No207QA0401XAllopathic & Osteopathic PhysiciansFamily MedicineAddiction MedicineGroup - Multi-Specialty
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty