Provider Demographics
NPI:1568916930
Name:STETSER, KELLY ANN (MS, AT, ATC, CEIS)
Entity Type:Individual
Prefix:MS
First Name:KELLY
Middle Name:ANN
Last Name:STETSER
Suffix:
Gender:F
Credentials:MS, AT, ATC, CEIS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4182 PINE CREEK RD SW
Mailing Address - Street 2:APT 4
Mailing Address - City:GRANDVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:49418-2528
Mailing Address - Country:US
Mailing Address - Phone:248-217-4565
Mailing Address - Fax:616-748-7033
Practice Address - Street 1:725 E MAIN AVE
Practice Address - Street 2:
Practice Address - City:ZEELAND
Practice Address - State:MI
Practice Address - Zip Code:49464-1331
Practice Address - Country:US
Practice Address - Phone:616-748-7234
Practice Address - Fax:616-748-7033
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-15
Last Update Date:2016-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIS332465067653252Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes252Y00000XAgenciesEarly Intervention Provider Agency