Organization
KELATESS PC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
DR. MATTHEW P. DICKSON PHD (PRESIDENT)
(810) 606-1099
Entity
Organization
Contact information
Practice address
1441 E MAPLE AVE, BURTON, MI 48529-2059
(810) 820-6265
Mailing address
7382 MOHANSIC DR, BLOOMFIELD HILLS, MI 48301-3552
(810) 606-1099
Taxonomy
Speciality
Code
Description
License number
State
103TC0700X
Clinical Psychologist
Primary
6301006835
MI
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
680F33159
BLUE CROSS
MI
Enumeration date
07/11/2006
Last updated
11/30/2016
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