Provider Demographics
NPI:1578606794
Name:KELLY, MICHELLE (OTR)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:KELLY
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:520 OAKVIEW DR
Mailing Address - Street 2:
Mailing Address - City:SLINGER
Mailing Address - State:WI
Mailing Address - Zip Code:53086-9593
Mailing Address - Country:US
Mailing Address - Phone:262-644-7491
Mailing Address - Fax:
Practice Address - Street 1:5595 COUNTY ROAD Z
Practice Address - Street 2:
Practice Address - City:WEST BEND
Practice Address - State:WI
Practice Address - Zip Code:53095-9224
Practice Address - Country:US
Practice Address - Phone:262-306-2100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-15
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3817-26225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI41044200Medicaid