Healthcare Provider Details

I. General information

NPI: 1689738320
Provider Name (Legal Business Name): KELLY ANN BEAUDRY-RODGERS M.S, C.G.C.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/20/2006
Last Update Date: 01/26/2024
Certification Date: 01/26/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3535 W 13 MILE RD STE N300
ROYAL OAK MI
48073-6770
US

IV. Provider business mailing address

3535 W 13 MILE RD SUITE 329
ROYAL OAK MI
48073-6710
US

V. Phone/Fax

Practice location:
  • Phone: 248-551-3302
  • Fax: 248-551-7373
Mailing address:
  • Phone: 248-441-0395
  • Fax: 248-551-3130

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code170300000X
TaxonomyGenetic Counselor (M.S.)
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code170300000X
TaxonomyGenetic Counselor (M.S.)
License Number7201000148
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: