Healthcare Provider Details

I. General information

NPI: 1457979239
Provider Name (Legal Business Name): KELLY LEANN LOVORN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/08/2020
Last Update Date: 01/31/2022
Certification Date: 01/31/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

31557 SCHOOLCRAFT RD STE 200
LIVONIA MI
48150-1848
US

IV. Provider business mailing address

350 N MAIN ST STE 220
CHELSEA MI
48118-1635
US

V. Phone/Fax

Practice location:
  • Phone: 734-474-2958
  • Fax:
Mailing address:
  • Phone: 734-433-5100
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6851110812
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: