Provider Demographics
NPI:1720393515
Name:MCLEAN, KELLY DENISE (MT, RMT)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:DENISE
Last Name:MCLEAN
Suffix:
Gender:F
Credentials:MT, RMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7070 AUSTRIAN PINE WAY
Mailing Address - Street 2:#4
Mailing Address - City:PORTAGE
Mailing Address - State:MI
Mailing Address - Zip Code:49024-3972
Mailing Address - Country:US
Mailing Address - Phone:269-744-2107
Mailing Address - Fax:
Practice Address - Street 1:7070 AUSTRIAN PINE WAY
Practice Address - Street 2:#4
Practice Address - City:PORTAGE
Practice Address - State:MI
Practice Address - Zip Code:49024-3972
Practice Address - Country:US
Practice Address - Phone:269-744-2107
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-08-17
Last Update Date:2011-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist