Provider Demographics
NPI:1730803883
Name:VINCENT, KELLIE (LLMSW)
Entity type:Individual
Prefix:MRS
First Name:KELLIE
Middle Name:
Last Name:VINCENT
Suffix:
Gender:F
Credentials:LLMSW
Other - Prefix:
Other - First Name:KELLIE
Other - Middle Name:
Other - Last Name:DEVAUGHN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LLMSW
Mailing Address - Street 1:29314 MEADOWLARK ST
Mailing Address - Street 2:
Mailing Address - City:LIVONIA
Mailing Address - State:MI
Mailing Address - Zip Code:48154-4580
Mailing Address - Country:US
Mailing Address - Phone:765-541-8635
Mailing Address - Fax:
Practice Address - Street 1:5340 PLYMOUTH RD STE 104
Practice Address - Street 2:
Practice Address - City:ANN ARBOR
Practice Address - State:MI
Practice Address - Zip Code:48105-9557
Practice Address - Country:US
Practice Address - Phone:765-541-8635
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-10-03
Last Update Date:2022-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68511102851041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical