Provider Demographics
NPI:1033778972
Name:KELLEY, HEIDI L
Entity Type:Individual
Prefix:
First Name:HEIDI
Middle Name:L
Last Name:KELLEY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3901 NESTROM RD
Mailing Address - Street 2:
Mailing Address - City:WHITEHALL
Mailing Address - State:MI
Mailing Address - Zip Code:49461-9714
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1740 VILLAGE DR
Practice Address - Street 2:
Practice Address - City:MUSKEGON
Practice Address - State:MI
Practice Address - Zip Code:49442-4282
Practice Address - Country:US
Practice Address - Phone:231-672-2700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-12
Last Update Date:2019-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant