Provider Demographics
NPI:1639464894
Name:CAMPBELL, KELLY RENEE (OT)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:RENEE
Last Name:CAMPBELL
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7901 S 12TH ST
Mailing Address - Street 2:SUITE #200
Mailing Address - City:PORTAGE
Mailing Address - State:MI
Mailing Address - Zip Code:49024-3831
Mailing Address - Country:US
Mailing Address - Phone:269-372-7200
Mailing Address - Fax:
Practice Address - Street 1:7901 S 12TH ST
Practice Address - Street 2:SUITE #200
Practice Address - City:PORTAGE
Practice Address - State:MI
Practice Address - Zip Code:49024-3831
Practice Address - Country:US
Practice Address - Phone:269-372-7200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-06-16
Last Update Date:2011-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5201007870225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN5201007870OtherLICENSE