Provider Demographics
NPI:1114385465
Name:KELLY, ROBERT (LMT)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:
Last Name:KELLY
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:124 PEARL ST
Mailing Address - Street 2:STE 606
Mailing Address - City:YPSILANTI
Mailing Address - State:MI
Mailing Address - Zip Code:48197-2663
Mailing Address - Country:US
Mailing Address - Phone:734-480-8536
Mailing Address - Fax:
Practice Address - Street 1:124 PEARL ST
Practice Address - Street 2:STE 606
Practice Address - City:YPSILANTI
Practice Address - State:MI
Practice Address - Zip Code:48197-2663
Practice Address - Country:US
Practice Address - Phone:734-480-8536
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-02-02
Last Update Date:2016-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI7501003337225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist