Provider Demographics
NPI:1194218214
Name:KERRY, MELANE (OTRL)
Entity Type:Individual
Prefix:
First Name:MELANE
Middle Name:
Last Name:KERRY
Suffix:
Gender:F
Credentials:OTRL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3870 BABCOCK RD
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:MI
Mailing Address - Zip Code:48450-9525
Mailing Address - Country:US
Mailing Address - Phone:810-841-5570
Mailing Address - Fax:
Practice Address - Street 1:2601 ELECTRIC AVE
Practice Address - Street 2:
Practice Address - City:PORT HURON
Practice Address - State:MI
Practice Address - Zip Code:48060-6587
Practice Address - Country:US
Practice Address - Phone:810-216-1800
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-13
Last Update Date:2018-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5201009068225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1306227764Medicaid