Provider Demographics
NPI:1346753209
Name:RILEY, KATHRYN PELLEGROM (PT)
Entity Type:Individual
Prefix:
First Name:KATHRYN
Middle Name:PELLEGROM
Last Name:RILEY
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5931 SUMMERFIELD CT
Mailing Address - Street 2:
Mailing Address - City:HASLETT
Mailing Address - State:MI
Mailing Address - Zip Code:48840-8998
Mailing Address - Country:US
Mailing Address - Phone:517-896-3145
Mailing Address - Fax:
Practice Address - Street 1:1790 PACKARD HWY
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:MI
Practice Address - Zip Code:48813-9717
Practice Address - Country:US
Practice Address - Phone:517-541-8747
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-11-14
Last Update Date:2017-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501005391225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist