Provider Demographics
NPI:1700355500
Name:KISH, KELLY
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:KISH
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 1:32 S HOMER RD
Mailing Address - Street 2:
Mailing Address - City:MIDLAND
Mailing Address - State:MI
Mailing Address - Zip Code:48640-8367
Mailing Address - Country:US
Mailing Address - Phone:989-486-8351
Mailing Address - Fax:
Practice Address - Street 1:32 S HOMER RD
Practice Address - Street 2:
Practice Address - City:MIDLAND
Practice Address - State:MI
Practice Address - Zip Code:48640-8367
Practice Address - Country:US
Practice Address - Phone:989-486-8351
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-11-21
Last Update Date:2020-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician