Provider Demographics
NPI:1356436208
Name:KAIKKONEN, KELLY M
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:M
Last Name:KAIKKONEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 772263
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48277-2263
Mailing Address - Country:US
Mailing Address - Phone:810-441-0045
Mailing Address - Fax:
Practice Address - Street 1:8245 HOLLY RD STE 200
Practice Address - Street 2:
Practice Address - City:GRAND BLANC
Practice Address - State:MI
Practice Address - Zip Code:48439-2483
Practice Address - Country:US
Practice Address - Phone:800-693-1916
Practice Address - Fax:248-605-3525
Is Sole Proprietor?:No
Enumeration Date:2006-10-04
Last Update Date:2022-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401006044101Y00000X
MI6301009779103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical