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General NPI Number Information
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NPI Number | 1265150767
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Entity Type | Organization
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Legal Business Name | KELLY OTP LLC
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Dates
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Enumeration Date | 08/19/2022
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Last Update Date | 08/16/2023
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Provider Practice Location Address
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Address Line | 25200 KELLY RD
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City | ROSEVILLE
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State | MI
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Zip | 48066-4473
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Country | US
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Telephone | 586-422-1250
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Fax |
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Provider Business Mailing Address
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Address Line | 7 RIVERBANK DR
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City | BEVERLY HILLS
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State | MI
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Zip | 48025-4800
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Country | US
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Telephone | 248-971-0150
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Fax |
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Authorized Official
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Title or Position | PRATICE ADMINISTRATOR
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Name | AARON DOUGLAS ALSTON
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Credential |
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Telephone | 248-971-0150
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YA0400X
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Taxonomy Name | Addiction (Substance Use Disorder) Counselor
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 103TC1900X
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Taxonomy Name | Counseling Psychologist
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License Number |
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License Number State |
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Taxonomy #4
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number |
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License Number State |
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Taxonomy #5
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Taxonomy Code | 207QA0401X
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Taxonomy Name | Addiction Medicine (Family Medicine) Physician
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License Number |
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License Number State |
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Taxonomy #6
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Taxonomy Code | 261QM0801X
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Taxonomy Name | Mental Health Clinic/Center (Including Community Mental Health Center)
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License Number |
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License Number State |
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Taxonomy #7
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Taxonomy Code | 261QM2500X
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Taxonomy Name | Medical Specialty Clinic/Center
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License Number |
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License Number State |
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Taxonomy #8
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Taxonomy Code | 261QM2800X
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Taxonomy Name | Methadone Clinic
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License Number |
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License Number State |
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