Healthcare Provider Details

I. General information

NPI: 1851343644
Provider Name (Legal Business Name): RICHARD KELLY LLP
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 05/17/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

812 E JOLLY RD STE 111
LANSING MI
48910-6818
US

IV. Provider business mailing address

812 E JOLLY RD STE 210
LANSING MI
48910-6818
US

V. Phone/Fax

Practice location:
  • Phone: 517-346-8312
  • Fax: 517-346-8291
Mailing address:
  • Phone: 517-346-8410
  • Fax: 517-346-8291

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number6301009912
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: