Healthcare Provider Details

I. General information

NPI: 1235578766
Provider Name (Legal Business Name): KELLY ANN GRAY-VAN BUREN LLBSW/QMRP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/18/2013
Last Update Date: 06/18/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2140 E ELLSWORTH RD
ANN ARBOR MI
48108-2552
US

IV. Provider business mailing address

555 TOWNER ST P.O. BOX 915
YPSILANTI MI
48198-5752
US

V. Phone/Fax

Practice location:
  • Phone: 734-222-3485
  • Fax: 734-222-3461
Mailing address:
  • Phone: 734-544-3000
  • Fax: 734-544-6732

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number6802086672
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: