Provider Demographics
NPI:1639517048
Name:ELSE, KELLEY ANN (OTRL)
Entity Type:Individual
Prefix:
First Name:KELLEY
Middle Name:ANN
Last Name:ELSE
Suffix:
Gender:F
Credentials:OTRL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1003 PEARSON ST
Mailing Address - Street 2:
Mailing Address - City:FERNDALE
Mailing Address - State:MI
Mailing Address - Zip Code:48220-1603
Mailing Address - Country:US
Mailing Address - Phone:248-250-4098
Mailing Address - Fax:
Practice Address - Street 1:10909 HANNAN RD
Practice Address - Street 2:
Practice Address - City:ROMULUS
Practice Address - State:MI
Practice Address - Zip Code:48174-1383
Practice Address - Country:US
Practice Address - Phone:734-893-1033
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-07
Last Update Date:2013-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5201007632225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist