Provider Demographics
NPI:1881364123
Name:MACAULAY, KELLY ANN (,BS,QMHP,QI/DDP,GCDF)
Entity type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:ANN
Last Name:MACAULAY
Suffix:
Gender:F
Credentials:,BS,QMHP,QI/DDP,GCDF
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 226
Mailing Address - Street 2:
Mailing Address - City:KEEGO HARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48320-0226
Mailing Address - Country:US
Mailing Address - Phone:248-978-8636
Mailing Address - Fax:248-573-0455
Practice Address - Street 1:1642 LAKEWAY DR
Practice Address - Street 2:
Practice Address - City:BLOOMFIELD HILLS
Practice Address - State:MI
Practice Address - Zip Code:48302-0033
Practice Address - Country:US
Practice Address - Phone:248-978-8636
Practice Address - Fax:248-573-0455
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-17
Last Update Date:2021-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical