Keely Louise Wagner, LLP, MS

Primary specialty

PsychologistTaxonomy code 103T00000X

License

6361007929 Issued in MI

Practice address

7640 Dixie Hwy Ste 155
Clarkston, MI 48346-2095

Phone

(248) 791-9266

NPI assigned

Oct 1, 2020

Last updated

Sep 4, 2024By the provider in NPPES

Sex

Female

Sole proprietor

No

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 2

Addresses

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

Medicare enrollment (NPD)

Not enrolled

Credentials

Master of Science

State licenses

Practice roles

Locations

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships, National Provider Directory roles and organizations whose NPPES authorized official is this provider.

• Innovations by Gomes Incorporated

  dba Ellie Mental Health - Clarkston

  • Mental Health Counselor
  • Clarkston, MI
  • NPI 1881389906
  NPD

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1601510400000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1725408000000",
    "number": "1518564657",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "2790 INTERNATIONAL DR APT 534C",
            "city": "YPSILANTI",
            "state": "MI",
            "postal_code": "481978527"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "7640 DIXIE HWY STE 155",
            "city": "CLARKSTON",
            "state": "MI",
            "postal_code": "483462095",
            "telephone_number": "248-791-9266"
        }
    ],
    "practiceLocations": [
        {
            "address_1": "315 N Center St",
            "address_purpose": "LOCATION",
            "city": "Northville",
            "state": "MI",
            "postal_code": "481671277",
            "country_code": "US",
            "telephone_number": "234-759-7191",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "basic": {
        "last_name": "WAGNER",
        "first_name": "KEELY",
        "middle_name": "LOUISE",
        "credential": "LLP, MS",
        "sole_proprietor": "NO",
        "sex": "F",
        "enumeration_date": "2020-10-01",
        "last_updated": "2024-09-04",
        "certification_date": "2024-09-04",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "101YM0800X",
            "taxonomy_group": "",
            "desc": "Counselor, Mental Health",
            "state": "MI",
            "license": "6362009086",
            "primary": false
        },
        {
            "code": "103T00000X",
            "taxonomy_group": "",
            "desc": "Psychologist",
            "state": "MI",
            "license": "6361007929",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

• Vip Fitness LLC
• Kimberly Marie Visintine, DNP, APRN, FNP
• Visiting Nurse Services of Michigan (McLaren Home Medical)
• Zachary David Voyles
• Amy Wade
• Lynette Ann Wagner, OTR/L
• Waldon Internal Medicine
• Walgreen Co
• Walgreen Co (Walgreens #05171)
• Monica Walker, RN

• Psychologist in Clarkston, MI
• Providers in Clarkston, MI by specialty
• Psychologist in Michigan

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Sep 4, 2024; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.