MEDICARE: KELSEY GAULT LMSW, C-SSWS

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	1041C0700X	Clinical Social Worker	6801105967	MI
2	1041S0200X	School Social Worker	6801105967	MI
3	104100000X	Social Worker	6801105967	MI

General Provider Information

NPI Number	:	1487055489
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KELSEY GAULT LMSW, C-SSWS

Provider Business Mailing Address
First Line	:	38621 DARBYSHIRE
Second Line	:
City	:	FARMINGTON HILLS
State	:	MI
Zip	:	48331-2881
Country	:	US
Telephone Number	:
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	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/09/2014
Last Update Date	:	10/22/2024

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