Provider Demographics
NPI:1730582388
Name:O'NEILL, KELLY
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:O'NEILL
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 1:31557 SCHOOLCRAFT RD STE 200
Mailing Address - Street 2:
Mailing Address - City:LIVONIA
Mailing Address - State:MI
Mailing Address - Zip Code:48150-1848
Mailing Address - Country:US
Mailing Address - Phone:248-765-6896
Mailing Address - Fax:
Practice Address - Street 1:31557 SCHOOLCRAFT RD STE 200
Practice Address - Street 2:
Practice Address - City:LIVONIA
Practice Address - State:MI
Practice Address - Zip Code:48150-1848
Practice Address - Country:US
Practice Address - Phone:248-765-6896
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-09-26
Last Update Date:2021-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
0-14-6138106E00000X, 106E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior Analyst