Provider Demographics
NPI:1346017266
Name:TRACY, KELLEY-BETH (COTA/L)
Entity Type:Individual
Prefix:
First Name:KELLEY-BETH
Middle Name:
Last Name:TRACY
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:KELLEY-BETH
Other - Middle Name:
Other - Last Name:PETERS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:216 HARRISON ST APT 103
Mailing Address - Street 2:
Mailing Address - City:CHELSEA
Mailing Address - State:MI
Mailing Address - Zip Code:48118-1068
Mailing Address - Country:US
Mailing Address - Phone:734-395-2969
Mailing Address - Fax:
Practice Address - Street 1:3310 W COMMERCE RD
Practice Address - Street 2:
Practice Address - City:MILFORD
Practice Address - State:MI
Practice Address - Zip Code:48380-3100
Practice Address - Country:US
Practice Address - Phone:248-685-1400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-12-11
Last Update Date:2023-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5202008394224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant