Provider Demographics
NPI:1033963160
Name:EAGER-KELLY, SUMMER ELISE (PRC)
Entity type:Individual
Prefix:MRS
First Name:SUMMER
Middle Name:ELISE
Last Name:EAGER-KELLY
Suffix:
Gender:F
Credentials:PRC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:28303 DEQUINDRE RD STE 100
Mailing Address - Street 2:
Mailing Address - City:MADISON HEIGHTS
Mailing Address - State:MI
Mailing Address - Zip Code:48071-3040
Mailing Address - Country:US
Mailing Address - Phone:248-658-1116
Mailing Address - Fax:
Practice Address - Street 1:28303 DEQUINDRE RD STE 100
Practice Address - Street 2:
Practice Address - City:MADISON HEIGHTS
Practice Address - State:MI
Practice Address - Zip Code:48071-3040
Practice Address - Country:US
Practice Address - Phone:248-658-1116
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-04-15
Last Update Date:2025-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI175T00000X
106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Yes175T00000XOther Service ProvidersPeer Specialist