Healthcare Provider Details

I. General information

NPI: 1942741301
Provider Name (Legal Business Name): JOHN KETTLEY MSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/17/2017
Last Update Date: 03/17/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1221 W NORTH TERRITORIAL RD
ANN ARBOR MI
48105-9222
US

IV. Provider business mailing address

1221 W NORTH TERRITORIAL RD
ANN ARBOR MI
48105-9222
US

V. Phone/Fax

Practice location:
  • Phone: 734-358-7116
  • Fax:
Mailing address:
  • Phone: 734-358-7116
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6801010281
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number6801010281
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: