MEDICARE: KELSEY GAULT THERAPY PLLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	104100000X	Social Worker

General Provider Information

NPI Number	:	1124847975
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KELSEY GAULT THERAPY PLLC

Provider Business Mailing Address
First Line	:	38621 DARBYSHIRE
Second Line	:
City	:	FARMINGTON HILLS
State	:	MI
Zip	:	48331-2881
Country	:	US
Telephone Number	:	248-826-4558
Fax Number	:

Provider Business Practice Location Address
First Line	:	38621 DARBYSHIRE
Second Line	:
City	:	FARMINGTON HILLS
State	:	MI
Zip	:	48331-2881
Country	:	US
Telephone Number	:	248-462-6764
Fax Number	:

Authorized Official
Title or Position	:	SOCIAL WORKER/OWNER
Name	:	KELSEY GAULT
Credential	:	LMSW-C, C-SSWS
Telephone Number	:	248-826-4558

Provider Enumeration Date	:	10/08/2024
Last Update Date	:	10/22/2024

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