Healthcare Provider Details

I. General information

NPI: 1760299747
Provider Name (Legal Business Name): KELLY REAN KOERNER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/13/2024
Last Update Date: 12/13/2024
Certification Date: 12/13/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3003 E MICHIGAN AVE STE 1139
LANSING MI
48912-4616
US

IV. Provider business mailing address

601 CAMROSE CT
LAINGSBURG MI
48848-9809
US

V. Phone/Fax

Practice location:
  • Phone: 517-816-9018
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: