=====================================================
General NPI Number Information
=====================================================
NPI Number | 1598956948
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KELLIE M YOST M.A., LLP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/09/2007
-----------------------------------------------------
Last Update Date | 11/10/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 23975 NOVI RD SUITE C-101
-----------------------------------------------------
City | NOVI
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48375-2459
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 517-367-0670
-----------------------------------------------------
Fax | 517-367-0681
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 25314 CROWN POINT CT
-----------------------------------------------------
City | FARMINGTON HILLS
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48335-1234
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 517-677-2414
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103T00000X
-----------------------------------------------------
Taxonomy Name | Psychologist
-----------------------------------------------------
License Number | 6301012258
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------