Healthcare Provider Details

I. General information

NPI: 1730815440
Provider Name (Legal Business Name): KELSY RAE THOM SST,QMHP,QIDP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/26/2022
Last Update Date: 07/26/2022
Certification Date: 07/26/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

715 PYLE DR
KINGSFORD MI
49802-4456
US

IV. Provider business mailing address

715 PYLE DR
KINGSFORD MI
49802-4456
US

V. Phone/Fax

Practice location:
  • Phone: 906-282-3255
  • Fax: 906-779-1306
Mailing address:
  • Phone: 906-282-3255
  • Fax: 906-779-1306

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6803087179
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: