Provider Demographics
NPI:1720502685
Name:TOGGWEILER, KELLY
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:TOGGWEILER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:
Other - Last Name:TRUESDALE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:32523 WISCONSIN ST
Mailing Address - Street 2:
Mailing Address - City:LIVONIA
Mailing Address - State:MI
Mailing Address - Zip Code:48150-3717
Mailing Address - Country:US
Mailing Address - Phone:586-883-2169
Mailing Address - Fax:
Practice Address - Street 1:10524 GRAND RIVER RD STE 100
Practice Address - Street 2:
Practice Address - City:BRIGHTON
Practice Address - State:MI
Practice Address - Zip Code:48116-9559
Practice Address - Country:US
Practice Address - Phone:810-225-3417
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-01
Last Update Date:2020-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
6301017132103T00000X
MI6301017132103T00000X
6362008020103T00000X
MI6362008020103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist