Healthcare Provider Details

I. General information

NPI: 1245145176
Provider Name (Legal Business Name): KELLY DIANE CRONK
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/17/2026
Last Update Date: 08/17/2026
Certification Date: 08/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

210 TOWN CENTER DR
TROY MI
48084-1774
US

IV. Provider business mailing address

37565 LAKEVILLE ST
HARRISON TOWNSHIP MI
48045-2880
US

V. Phone/Fax

Practice location:
  • Phone: 248-643-8900
  • Fax:
Mailing address:
  • Phone: 248-882-4998
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number7101003466
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: