Healthcare Provider Details

I. General information

NPI: 1356436208
Provider Name (Legal Business Name): KELLY M. KAIKKONEN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/04/2006
Last Update Date: 08/17/2022
Certification Date: 08/17/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8245 HOLLY RD STE 200
GRAND BLANC MI
48439-2483
US

IV. Provider business mailing address

PO BOX 772263
DETROIT MI
48277-2263
US

V. Phone/Fax

Practice location:
  • Phone: 800-693-1916
  • Fax: 248-605-3525
Mailing address:
  • Phone: 810-441-0045
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number6401006044
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number6301009779
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: