Provider Demographics
NPI:1376861112
Name:MCCARTHY, KELLY ANNE (DPT)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:ANNE
Last Name:MCCARTHY
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2699 DANSBURY CT
Mailing Address - Street 2:
Mailing Address - City:LAKE ORION
Mailing Address - State:MI
Mailing Address - Zip Code:48360-1605
Mailing Address - Country:US
Mailing Address - Phone:248-736-5837
Mailing Address - Fax:
Practice Address - Street 1:10809 S SAGINAW ST
Practice Address - Street 2:
Practice Address - City:GRAND BLANC
Practice Address - State:MI
Practice Address - Zip Code:48439-7033
Practice Address - Country:US
Practice Address - Phone:810-695-8700
Practice Address - Fax:810-695-7946
Is Sole Proprietor?:Yes
Enumeration Date:2010-05-04
Last Update Date:2011-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501015147225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI236629Medicare PIN