Healthcare Provider Details

I. General information

NPI: 1124486998
Provider Name (Legal Business Name): KELLI LAWRENCE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/08/2016
Last Update Date: 02/08/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5130 ROSE HILL BLVD
HOLLY MI
48442-9507
US

IV. Provider business mailing address

5130 ROSE HILL BLVD
HOLLY MI
48442-9507
US

V. Phone/Fax

Practice location:
  • Phone: 248-634-5530
  • Fax: 248-634-7754
Mailing address:
  • Phone: 248-634-5530
  • Fax: 248-634-7754

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6801098293
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: