Provider Demographics
NPI:1568887438
Name:BARAN, KELLY (PTA)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:BARAN
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:
Other - Last Name:RICHARDS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PTA
Mailing Address - Street 1:8481 HOLLY RD
Mailing Address - Street 2:
Mailing Address - City:GRAND BLANC
Mailing Address - State:MI
Mailing Address - Zip Code:48439-1812
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:8481 HOLLY RD
Practice Address - Street 2:
Practice Address - City:GRAND BLANC
Practice Address - State:MI
Practice Address - Zip Code:48439-1812
Practice Address - Country:US
Practice Address - Phone:810-694-1711
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-02-28
Last Update Date:2014-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5502003106225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant