Provider Demographics
NPI:1104390426
Name:BUCKHANNON KERLEY, LYNDELL (OTR)
Entity Type:Individual
Prefix:
First Name:LYNDELL
Middle Name:
Last Name:BUCKHANNON KERLEY
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3325 WEST DR
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MI
Mailing Address - Zip Code:49201-7719
Mailing Address - Country:US
Mailing Address - Phone:517-740-7406
Mailing Address - Fax:
Practice Address - Street 1:34505 W 12 MILE RD STE 100
Practice Address - Street 2:
Practice Address - City:FARMINGTON HILLS
Practice Address - State:MI
Practice Address - Zip Code:48331-3287
Practice Address - Country:US
Practice Address - Phone:855-559-7178
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-21
Last Update Date:2019-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5201004097225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist