NPIMap

Individual provider Active NPI

Kelly D Distelrath, LLP

  • Clinical Psychologist
  • Port Huron, MI
National Provider Identifier
1598976375
Registry record updated Mar 3, 2021
On this page

Key facts

NPPES NPI Registry
Primary specialty
Clinical PsychologistTaxonomy code 103TC0700X
License
6361007549 Issued in MI
Practice address
520 Superior St
Port Huron, MI 48060-3838
Phone
(810) 984-4202
NPI assigned
May 24, 2007
Sex
Female
Sole proprietor
No

NPPES NPI Registry

Updated by the provider on Mar 3, 2021

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

Specialties & licenses 2

Specialty (taxonomy)CodeLicenseStatePrimary
Mental Health Counselor 101YM0800X
Clinical Psychologist 103TC0700X 6361007549 MI Primary

Addresses

Primary practice location

520 Superior St
Port Huron, MI 48060-3838

Mailing address

1340 Pinecrest Dr
Ferndale, MI 48220-1608
Phone (586) 258-0206

Other practice location 1

12220 E 13 Mile Rd
Suite 300
Warren, MI 48093-5000
Phone (586) 258-0206 ext. 119

Other names 1

  • Kelly D Hadden Former name

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Not listed in the public Medicare enrollment file

National Provider Directory

National Provider Directory
Medicare enrollment (NPD)
Not enrolled

State licenses

LicenseStateTypeSpecialty
6361007549MIMDClinical Psychologist

Practice roles

OrganizationSpecialtyStatusNew patients
Judson Center, Inc. Past Accepting new patients
Pure Psychiatry of Michigan PLLC PastSince Jul 24, 2023 Accepting new patients

Organizations & group practices 2

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

NPI Registry JSON

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

{
    "created_epoch": "1179964800000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1614729600000",
    "number": "1598976375",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1340 PINECREST DR",
            "city": "FERNDALE",
            "state": "MI",
            "postal_code": "482201608",
            "telephone_number": "586-258-0206",
            "fax_number": "586-258-0201"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "520 SUPERIOR ST",
            "city": "PORT HURON",
            "state": "MI",
            "postal_code": "480603838",
            "telephone_number": "810-984-4202"
        }
    ],
    "practiceLocations": [
        {
            "address_1": "12220 E 13 Mile Rd",
            "address_2": "Suite 300",
            "address_purpose": "LOCATION",
            "city": "Warren",
            "state": "MI",
            "postal_code": "480935000",
            "country_code": "US",
            "telephone_number": "586-258-0206 x119",
            "fax_number": "586-258-0201",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "basic": {
        "last_name": "DISTELRATH",
        "first_name": "KELLY",
        "middle_name": "D",
        "credential": "LLP",
        "sole_proprietor": "NO",
        "sex": "F",
        "enumeration_date": "2007-05-24",
        "last_updated": "2021-03-03",
        "certification_date": "2021-03-03",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "101YM0800X",
            "taxonomy_group": "",
            "desc": "Counselor, Mental Health",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "103TC0700X",
            "taxonomy_group": "",
            "desc": "Psychologist, Clinical",
            "state": "MI",
            "license": "6361007549",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "first_name": "KELLY",
            "last_name": "HADDEN",
            "middle_name": "D",
            "code": "1",
            "type": "Former Name"
        }
    ]
}

Other providers in Port Huron, MI

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Mar 3, 2021; 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.