Healthcare Provider Details

I. General information

NPI: 1699455535
Provider Name (Legal Business Name): M LUCILLE KELLEY LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: M LUCILLE KELLEY LPC

II. Dates (important events)

Enumeration Date: 07/24/2023
Last Update Date: 04/24/2026
Certification Date: 04/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

421 POPLAR RD
CENTERTON AR
72719-7944
US

IV. Provider business mailing address

421 POPLAR RD
CENTERTON AR
72719-7944
US

V. Phone/Fax

Practice location:
  • Phone: 248-701-9889
  • Fax:
Mailing address:
  • Phone: 248-701-9889
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License NumberP2511020
License Number StateAR
# 2
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number6401000490
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: