Healthcare Provider Details

I. General information

NPI: 1831547967
Provider Name (Legal Business Name): KELSEY PORADA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/31/2016
Last Update Date: 05/31/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3900 W BROWN DEER RD
BROWN DEER WI
53209-1220
US

IV. Provider business mailing address

32740 LIPAROTO DR
ROCKWOOD MI
48173-9667
US

V. Phone/Fax

Practice location:
  • Phone: 414-540-2170
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number3019-226
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: