Provider Demographics
NPI:1215302872
Name:KELLY, PATRICIA (LMSW)
Entity type:Individual
Prefix:
First Name:PATRICIA
Middle Name:
Last Name:KELLY
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:901 CHIPPEWA ST
Mailing Address - Street 2:
Mailing Address - City:FLINT
Mailing Address - State:MI
Mailing Address - Zip Code:48503-1552
Mailing Address - Country:US
Mailing Address - Phone:810-232-9950
Mailing Address - Fax:989-723-8230
Practice Address - Street 1:1480 N M 52 STE 1
Practice Address - Street 2:
Practice Address - City:OWOSSO
Practice Address - State:MI
Practice Address - Zip Code:48867-1025
Practice Address - Country:US
Practice Address - Phone:989-723-8239
Practice Address - Fax:989-723-8230
Is Sole Proprietor?:No
Enumeration Date:2015-12-08
Last Update Date:2024-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4703117696164W00000X
MI68011008171041C0700X
FLSW156781041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLPN 5197236OtherLPN LICENSE
FLISW 6560OtherREGISTERED CLINICAL SOCIAL WORKER INTERN