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NPI Code Detail

MEDICARE: KELLY M. KAIKKONEN

MEDICARE: KELLY M. KAIKKONEN
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1101Y00000XCounselor6401006044MI
2103TC0700XClinical Psychologist6301009779MI

General Provider Information

NPI Number : 1356436208
Entity Type Code : Individual
Provider Name (Legal Business Name) : KELLY M. KAIKKONEN
Provider Business Mailing Address
First Line : PO BOX 772263
Second Line :
City : DETROIT
State : MI
Zip : 48277-2263
Country : US
Telephone Number : 810-441-0045
Fax Number :
Provider Business Practice Location Address
First Line : 8245 HOLLY RD STE 200
Second Line :
City : GRAND BLANC
State : MI
Zip : 48439-2483
Country : US
Telephone Number : 800-693-1916
Fax Number : 248-605-3525
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 10/04/2006
Last Update Date : 08/17/2022

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