Provider Demographics
NPI:1679958664
Name:KELLY, DAVID SCOTT (MA,CAADC,MAC,CCS)
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:SCOTT
Last Name:KELLY
Suffix:
Gender:M
Credentials:MA,CAADC,MAC,CCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 M 66 N
Mailing Address - Street 2:
Mailing Address - City:CHARLEVOIX
Mailing Address - State:MI
Mailing Address - Zip Code:49720-9338
Mailing Address - Country:US
Mailing Address - Phone:231-547-1144
Mailing Address - Fax:231-547-4970
Practice Address - Street 1:101 M 66 N
Practice Address - Street 2:
Practice Address - City:CHARLEVOIX
Practice Address - State:MI
Practice Address - Zip Code:49720-9338
Practice Address - Country:US
Practice Address - Phone:231-547-1144
Practice Address - Fax:231-547-4970
Is Sole Proprietor?:No
Enumeration Date:2015-07-20
Last Update Date:2023-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MISA0150013101YA0400X
MI6802062018104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI20151209439760Medicaid