Provider Demographics
NPI:1124847975
Name:KELSEY GAULT THERAPY PLLC
Entity type:Organization
Organization Name:KELSEY GAULT THERAPY PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOCIAL WORKER/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KELSEY
Authorized Official - Middle Name:
Authorized Official - Last Name:GAULT
Authorized Official - Suffix:
Authorized Official - Credentials:LMSW-C, C-SSWS
Authorized Official - Phone:248-826-4558
Mailing Address - Street 1:38621 DARBYSHIRE
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48331-2881
Mailing Address - Country:US
Mailing Address - Phone:248-826-4558
Mailing Address - Fax:
Practice Address - Street 1:38621 DARBYSHIRE
Practice Address - Street 2:
Practice Address - City:FARMINGTON HILLS
Practice Address - State:MI
Practice Address - Zip Code:48331-2881
Practice Address - Country:US
Practice Address - Phone:248-462-6764
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-10-08
Last Update Date:2024-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
Yes104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Single Specialty
No261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health