Provider Demographics
NPI:1720124308
Name:THOMPSON, KELLY LYNN (LMSW)
Entity Type:Individual
Prefix:MS
First Name:KELLY
Middle Name:LYNN
Last Name:THOMPSON
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:LYNN
Other - Last Name:KANIGOWSKI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LMSW
Mailing Address - Street 1:5639 SASHABAW RD
Mailing Address - Street 2:
Mailing Address - City:CLARKSTON
Mailing Address - State:MI
Mailing Address - Zip Code:48346-3149
Mailing Address - Country:US
Mailing Address - Phone:248-922-9077
Mailing Address - Fax:
Practice Address - Street 1:5639 SASHABAW RD
Practice Address - Street 2:
Practice Address - City:CLARKSTON
Practice Address - State:MI
Practice Address - Zip Code:48346-3149
Practice Address - Country:US
Practice Address - Phone:248-922-9077
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-30
Last Update Date:2018-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6801066239104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker