Provider Demographics
NPI:1093367906
Name:SCALA, KELLY (AT, ATC)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:SCALA
Suffix:
Gender:F
Credentials:AT, ATC
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:
Other - Last Name:BEHEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:23261 CLEVELAND ST
Mailing Address - Street 2:
Mailing Address - City:DEARBORN
Mailing Address - State:MI
Mailing Address - Zip Code:48124-2551
Mailing Address - Country:US
Mailing Address - Phone:248-756-1343
Mailing Address - Fax:
Practice Address - Street 1:19501 OUTER DR
Practice Address - Street 2:
Practice Address - City:DEARBORN
Practice Address - State:MI
Practice Address - Zip Code:48124-1600
Practice Address - Country:US
Practice Address - Phone:248-756-1343
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-10
Last Update Date:2019-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI26010010442255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer