Provider Demographics
NPI:1881309482
Name:KELLY, OLIVIA ROSE (TLLP)
Entity type:Individual
Prefix:
First Name:OLIVIA
Middle Name:ROSE
Last Name:KELLY
Suffix:
Gender:F
Credentials:TLLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:31080 MCKINNEY DR
Mailing Address - Street 2:
Mailing Address - City:FRANKLIN
Mailing Address - State:MI
Mailing Address - Zip Code:48025-1313
Mailing Address - Country:US
Mailing Address - Phone:313-580-1890
Mailing Address - Fax:
Practice Address - Street 1:2075 W BIG BEAVER RD
Practice Address - Street 2:
Practice Address - City:TROY
Practice Address - State:MI
Practice Address - Zip Code:48084-3407
Practice Address - Country:US
Practice Address - Phone:248-646-6659
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-18
Last Update Date:2023-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6362009694103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling