Healthcare Provider Details

I. General information

NPI: 1518564657
Provider Name (Legal Business Name): KEELY LOUISE WAGNER LLP, MS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/01/2020
Last Update Date: 09/04/2024
Certification Date: 09/04/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7640 DIXIE HWY STE 155
CLARKSTON MI
48346-2095
US

IV. Provider business mailing address

2790 INTERNATIONAL DR APT 534C
YPSILANTI MI
48197-8527
US

V. Phone/Fax

Practice location:
  • Phone: 248-791-9266
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number6362009086
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number6361007929
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: