Provider Demographics
NPI:1316618135
Name:THOMAS, KELLY SUE (LBSW)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:SUE
Last Name:THOMAS
Suffix:
Gender:F
Credentials:LBSW
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:SUE
Other - Last Name:SHOUDER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LBSW
Mailing Address - Street 1:400 JOHNSON ST
Mailing Address - Street 2:
Mailing Address - City:ALPENA
Mailing Address - State:MI
Mailing Address - Zip Code:49707-1434
Mailing Address - Country:US
Mailing Address - Phone:989-356-7690
Mailing Address - Fax:
Practice Address - Street 1:400 JOHNSON ST
Practice Address - Street 2:
Practice Address - City:ALPENA
Practice Address - State:MI
Practice Address - Zip Code:49707-1434
Practice Address - Country:US
Practice Address - Phone:989-356-7690
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-22
Last Update Date:2021-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68020688341041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical