Healthcare Provider Details

I. General information

NPI: 1235760851
Provider Name (Legal Business Name): TONYA MICHELE KELLEY
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/01/2020
Last Update Date: 07/01/2026
Certification Date: 07/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21700 GREENFIELD RD STE 200
OAK PARK MI
48237-2538
US

IV. Provider business mailing address

21700 GREENFIELD RD STE 200
OAK PARK MI
48237-2538
US

V. Phone/Fax

Practice location:
  • Phone: 248-703-2199
  • Fax: 313-580-1822
Mailing address:
  • Phone: 248-703-2199
  • Fax: 313-580-1822

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number6451018416
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: