Provider Demographics
NPI:1285197624
Name:ROSENBERG, KELLIE BETH (LMT)
Entity Type:Individual
Prefix:
First Name:KELLIE
Middle Name:BETH
Last Name:ROSENBERG
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:44 TAFT ST
Mailing Address - Street 2:
Mailing Address - City:ZEELAND
Mailing Address - State:MI
Mailing Address - Zip Code:49464-1621
Mailing Address - Country:US
Mailing Address - Phone:616-312-9664
Mailing Address - Fax:
Practice Address - Street 1:117 COOLIDGE AVE
Practice Address - Street 2:
Practice Address - City:HOLLAND
Practice Address - State:MI
Practice Address - Zip Code:49423-3020
Practice Address - Country:US
Practice Address - Phone:616-312-9664
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-11
Last Update Date:2019-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI7501010056225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist