Provider Demographics
NPI:1699364497
Name:KELLEY, ROWAN (MS)
Entity type:Individual
Prefix:
First Name:ROWAN
Middle Name:
Last Name:KELLEY
Suffix:
Gender:M
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:210 E MAIN ST STE 201
Mailing Address - Street 2:
Mailing Address - City:NILES
Mailing Address - State:MI
Mailing Address - Zip Code:49120-2376
Mailing Address - Country:US
Mailing Address - Phone:269-224-0977
Mailing Address - Fax:269-224-0978
Practice Address - Street 1:210 E MAIN ST STE 201
Practice Address - Street 2:
Practice Address - City:NILES
Practice Address - State:MI
Practice Address - Zip Code:49120-2376
Practice Address - Country:US
Practice Address - Phone:269-224-0977
Practice Address - Fax:269-224-0978
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-15
Last Update Date:2025-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401225208101Y00000X
IN39004723A101Y00000X
101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor