MEDICARE: KELLEY LYNN GAVIGAN LMSW

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
1	1041C0700X	Clinical Social Worker	6801101391	MI
2	1041C0700X	Clinical Social Worker	6801109616	MI

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MI3861	OTHER	MI	MEDICARE

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1518483189
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KELLEY LYNN GAVIGAN LMSW

Provider Business Mailing Address
First Line	:	7125 ORCHARD LAKE RD STE 110
Second Line	:
City	:	WEST BLOOMFIELD
State	:	MI
Zip	:	48322-3616
Country	:	US
Telephone Number	:	248-702-6132
Fax Number	:	248-702-6133

Provider Business Practice Location Address
First Line	:	7125 ORCHARD LAKE RD STE 110
Second Line	:
City	:	WEST BLOOMFIELD
State	:	MI
Zip	:	48322-3616
Country	:	US
Telephone Number	:	248-702-6132
Fax Number	:	248-702-6133

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/16/2017
Last Update Date	:	04/24/2025

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Directions to “ KELLEY LYNN GAVIGAN LMSW” Practice Location

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