Provider Demographics
NPI:1144264573
Name:KELLY, KATHLEEN MARIE (AUD)
Entity type:Individual
Prefix:DR
First Name:KATHLEEN
Middle Name:MARIE
Last Name:KELLY
Suffix:
Gender:F
Credentials:AUD
Other - Prefix:DR
Other - First Name:KATHLEEN
Other - Middle Name:MARIE
Other - Last Name:BIRCHFIELD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:AUD
Mailing Address - Street 1:1101 N US HIGHWAY 31
Mailing Address - Street 2:
Mailing Address - City:PETOSKEY
Mailing Address - State:MI
Mailing Address - Zip Code:49770-9305
Mailing Address - Country:US
Mailing Address - Phone:231-489-1006
Mailing Address - Fax:231-753-3039
Practice Address - Street 1:2325 SUMMIT PARK DR
Practice Address - Street 2:SUITE B
Practice Address - City:PETOSKEY
Practice Address - State:MI
Practice Address - Zip Code:49770-8774
Practice Address - Country:US
Practice Address - Phone:231-347-1800
Practice Address - Fax:231-347-1864
Is Sole Proprietor?:No
Enumeration Date:2006-06-15
Last Update Date:2017-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI1601000052231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI640B410780OtherBCBS AUDIOLOGYPROVIDER ID
MI540B410790OtherBCBS HEARING PROVIDER ID
MI540B410790OtherBCBS HEARING PROVIDER ID
MIP14360001Medicare ID - Type UnspecifiedMEMBER NUMBER