Provider Demographics
NPI:1568779775
Name:KELLY, TIMOTHY MICHAEL (DPT)
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:MICHAEL
Last Name:KELLY
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 1:1800 W BIG BEAVER RD
Mailing Address - Street 2:SUITE 150
Mailing Address - City:TROY
Mailing Address - State:MI
Mailing Address - Zip Code:48084-3545
Mailing Address - Country:US
Mailing Address - Phone:248-649-2323
Mailing Address - Fax:248-649-5998
Practice Address - Street 1:1800 W BIG BEAVER RD
Practice Address - Street 2:SUITE 150
Practice Address - City:TROY
Practice Address - State:MI
Practice Address - Zip Code:48084-3545
Practice Address - Country:US
Practice Address - Phone:248-649-2323
Practice Address - Fax:248-649-5998
Is Sole Proprietor?:No
Enumeration Date:2010-09-09
Last Update Date:2010-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501015305225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist