Provider Demographics
NPI:1265819007
Name:MILLER, KELLY SUE (OTR/L)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:SUE
Last Name:MILLER
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1516 JONATHON DR
Mailing Address - Street 2:
Mailing Address - City:PORTAGE
Mailing Address - State:MI
Mailing Address - Zip Code:49002-6330
Mailing Address - Country:US
Mailing Address - Phone:269-599-6752
Mailing Address - Fax:
Practice Address - Street 1:5659 STADIUM DR STE A
Practice Address - Street 2:
Practice Address - City:KALAMAZOO
Practice Address - State:MI
Practice Address - Zip Code:49009-1932
Practice Address - Country:US
Practice Address - Phone:269-372-0436
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-04-30
Last Update Date:2015-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5201009141225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist