Healthcare Provider Details

I. General information

NPI: 1881309482
Provider Name (Legal Business Name): OLIVIA ROSE KELLY TLLP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/18/2023
Last Update Date: 01/18/2023
Certification Date: 01/04/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2075 W BIG BEAVER RD
TROY MI
48084-3407
US

IV. Provider business mailing address

31080 MCKINNEY DR
FRANKLIN MI
48025-1313
US

V. Phone/Fax

Practice location:
  • Phone: 248-646-6659
  • Fax:
Mailing address:
  • Phone: 313-580-1890
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number6362009694
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: