Provider Demographics
NPI:1407601560
Name:WARGO, KELSEY
Entity type:Individual
Prefix:
First Name:KELSEY
Middle Name:
Last Name:WARGO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16700 17 MILE RD
Mailing Address - Street 2:
Mailing Address - City:CLINTON TOWNSHIP
Mailing Address - State:MI
Mailing Address - Zip Code:48038-7325
Mailing Address - Country:US
Mailing Address - Phone:586-228-2300
Mailing Address - Fax:586-228-2300
Practice Address - Street 1:16700 17 MILE RD
Practice Address - Street 2:
Practice Address - City:CLINTON TOWNSHIP
Practice Address - State:MI
Practice Address - Zip Code:48038-7325
Practice Address - Country:US
Practice Address - Phone:586-228-2300
Practice Address - Fax:586-228-2300
Is Sole Proprietor?:No
Enumeration Date:2024-04-22
Last Update Date:2024-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIW620465298445106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician