Healthcare Provider Details

I. General information

NPI: 1376452144
Provider Name (Legal Business Name): KELLY CARDOZO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/05/2026
Last Update Date: 09/05/2026
Certification Date: 09/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1340 E SQUARE LAKE RD
TROY MI
48085-3326
US

IV. Provider business mailing address

48429 LINDON CT
SHELBY TOWNSHIP MI
48317-2632
US

V. Phone/Fax

Practice location:
  • Phone: 248-823-3100
  • Fax:
Mailing address:
  • Phone: 205-764-7721
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041S0200X
TaxonomySchool Social Worker
License Number6801122266
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: