Provider Demographics
NPI:1649534017
Name:NOVAK, KELLY LYN (MED)
Entity type:Individual
Prefix:MS
First Name:KELLY
Middle Name:LYN
Last Name:NOVAK
Suffix:
Gender:F
Credentials:MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1148 S HURON RD
Mailing Address - Street 2:
Mailing Address - City:KAWKAWLIN
Mailing Address - State:MI
Mailing Address - Zip Code:48631-9417
Mailing Address - Country:US
Mailing Address - Phone:989-615-0120
Mailing Address - Fax:
Practice Address - Street 1:500 HANCOCK ST
Practice Address - Street 2:
Practice Address - City:SAGINAW
Practice Address - State:MI
Practice Address - Zip Code:48602-4224
Practice Address - Country:US
Practice Address - Phone:989-797-3542
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-06-29
Last Update Date:2012-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI229752101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor