Provider Demographics
NPI:1407357403
Name:WILSON, KELLY LYNN (MS, OTRL)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:LYNN
Last Name:WILSON
Suffix:
Gender:F
Credentials:MS, OTRL
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:LYNN
Other - Last Name:BRIDGE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS, OTRL
Mailing Address - Street 1:928 DREON DR
Mailing Address - Street 2:
Mailing Address - City:CLAWSON
Mailing Address - State:MI
Mailing Address - Zip Code:48017-1014
Mailing Address - Country:US
Mailing Address - Phone:313-820-6866
Mailing Address - Fax:
Practice Address - Street 1:3601 W 13 MILE RD
Practice Address - Street 2:
Practice Address - City:ROYAL OAK
Practice Address - State:MI
Practice Address - Zip Code:48073-6712
Practice Address - Country:US
Practice Address - Phone:248-898-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-24
Last Update Date:2023-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5201009535225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist