Provider Demographics
NPI:1518218163
Name:LAWLESS, KELLEN D (DPT)
Entity Type:Individual
Prefix:
First Name:KELLEN
Middle Name:D
Last Name:LAWLESS
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:612 BAYBERRY POINTE DR NW
Mailing Address - Street 2:APT #J
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49534-4601
Mailing Address - Country:US
Mailing Address - Phone:989-906-3359
Mailing Address - Fax:
Practice Address - Street 1:1140 MONROE AVE NW
Practice Address - Street 2:SUITE 5201
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49503-1055
Practice Address - Country:US
Practice Address - Phone:616-401-2785
Practice Address - Fax:616-328-6585
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-23
Last Update Date:2012-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501016031225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist