Healthcare Provider Details

I. General information

NPI: 1841124740
Provider Name (Legal Business Name): KELLY DECLARK
Entity Type: Individual
Gender:
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/09/2026
Last Update Date: 06/09/2026
Certification Date: 06/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10483 DIXIE HWY
HOLLY MI
48442-9311
US

IV. Provider business mailing address

10483 DIXIE HWY
HOLLY MI
48442-9311
US

V. Phone/Fax

Practice location:
  • Phone: 810-771-7686
  • Fax:
Mailing address:
  • Phone: 810-771-7686
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number7152001440
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: