Provider Demographics
NPI:1417282864
Name:KELLY, STEPHANIE JOSEPHINE (DC)
Entity Type:Individual
Prefix:DR
First Name:STEPHANIE
Middle Name:JOSEPHINE
Last Name:KELLY
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:39680 W 14 MILE RD
Mailing Address - Street 2:
Mailing Address - City:WALLED LAKE
Mailing Address - State:MI
Mailing Address - Zip Code:48390-3909
Mailing Address - Country:US
Mailing Address - Phone:248-960-8828
Mailing Address - Fax:248-960-8829
Practice Address - Street 1:3302 CROOKS RD
Practice Address - Street 2:
Practice Address - City:ROYAL OAK
Practice Address - State:MI
Practice Address - Zip Code:48073-2446
Practice Address - Country:US
Practice Address - Phone:248-629-6071
Practice Address - Fax:248-629-6073
Is Sole Proprietor?:No
Enumeration Date:2009-10-02
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038.011438111N00000X
MI2301010312111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor