Individual
KELLY D DISTELRATH
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
LLP
Contact information
Practice address
520 SUPERIOR ST, PORT HURON, MI 48060-3838
(810) 984-4202
Mailing address
1340 PINECREST DR, FERNDALE, MI 48220-1608
(586) 258-0206
(586) 258-0201
Taxonomy
Speciality
Code
Description
License number
State
101YM0800X
Mental Health Counselor
—
—
103TC0700X
Clinical Psychologist
Primary
6361007549
MI
Other
Enumeration date
05/24/2007
Last updated
03/03/2021
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