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NPI Code Detail

MEDICARE: KELLY QUEEN LPC

MEDICARE: KELLY QUEEN LPC
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
1101Y00000XCounselor6401007827MI
2101YP2500XProfessional Counselor6401007827MI

General Provider Information

NPI Number : 1861590283
Entity Type Code : Individual
Provider Name (Legal Business Name) : KELLY QUEEN LPC
Provider Business Mailing Address
First Line : 2825 LIVERNOIS RD
Second Line :
City : TROY
State : MI
Zip : 48083-1214
Country : US
Telephone Number : 248-680-2060
Fax Number :
Provider Business Practice Location Address
First Line : 2825 LIVERNOIS RD
Second Line :
City : TROY
State : MI
Zip : 48083-1214
Country : US
Telephone Number : 248-680-2060
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 09/20/2006
Last Update Date : 04/03/2024

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Directions to “ KELLY QUEEN LPC” Practice Location

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