Healthcare Provider Details

I. General information

NPI: 1447173190
Provider Name (Legal Business Name): KELLY MATTINGLY LMSW
Entity Type: Individual
Gender:
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/31/2026
Last Update Date: 07/31/2026
Certification Date: 07/31/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3645 LONE TREE RD
MILFORD MI
48380-1937
US

IV. Provider business mailing address

3645 LONE TREE RD
MILFORD MI
48380-1937
US

V. Phone/Fax

Practice location:
  • Phone: 810-874-3020
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041S0200X
TaxonomySchool Social Worker
License Number6801092798
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: