Healthcare Provider Details

I. General information

NPI: 1174794382
Provider Name (Legal Business Name): MRS. KERRY KELLY NOVICK
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/14/2008
Last Update Date: 03/14/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

617 STRATFORD DR
ANN ARBOR MI
48104-2745
US

IV. Provider business mailing address

617 STRATFORD DR
ANN ARBOR MI
48104-2745
US

V. Phone/Fax

Practice location:
  • Phone: 734-665-6745
  • Fax: 734-665-2875
Mailing address:
  • Phone: 734-665-6745
  • Fax: 734-665-2875

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code102L00000X
TaxonomyPsychoanalyst
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: