Healthcare Provider Details

I. General information

NPI: 1407494792
Provider Name (Legal Business Name): DEBORAH JEAN KELLY LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: DEBORAH JEAN GEYMER

II. Dates (important events)

Enumeration Date: 12/17/2019
Last Update Date: 08/25/2026
Certification Date: 08/25/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

555 CEDAR ST
PAW PAW MI
49079-1182
US

IV. Provider business mailing address

555 CEDAR ST
PAW PAW MI
49079-1182
US

V. Phone/Fax

Practice location:
  • Phone: 269-415-5678
  • Fax:
Mailing address:
  • Phone: 269-415-5678
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number6401224816
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: