Provider Demographics
NPI:1558790840
Name:WAITE, KELLY K (LCSW)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:K
Last Name:WAITE
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1680 HARWICK PINES ROAD
Mailing Address - Street 2:
Mailing Address - City:GRAYLING
Mailing Address - State:MI
Mailing Address - Zip Code:49738
Mailing Address - Country:US
Mailing Address - Phone:989-344-2002
Mailing Address - Fax:
Practice Address - Street 1:1680 HARTWICK PINES RD
Practice Address - Street 2:
Practice Address - City:GRAYLING
Practice Address - State:MI
Practice Address - Zip Code:49738-9237
Practice Address - Country:US
Practice Address - Phone:989-344-2002
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-11-06
Last Update Date:2025-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC0110311041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical