Healthcare Provider Details

I. General information

NPI: 1326185711
Provider Name (Legal Business Name): DIANE MARIE MCKELVIE MALLP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/01/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

33975 DEQUINDRE RD SUITE 5
TROY MI
48083-4649
US

IV. Provider business mailing address

3237 BACON AVE
BERKLEY MI
48072-1150
US

V. Phone/Fax

Practice location:
  • Phone: 248-585-3239
  • Fax: 248-616-9759
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number6301009971
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: