Provider Demographics
NPI:1750640801
Name:WOOD, KELLY MARIE (PTA)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:MARIE
Last Name:WOOD
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3630 COBBLEFIELD CIR SE APT 10
Mailing Address - Street 2:
Mailing Address - City:CALEDONIA
Mailing Address - State:MI
Mailing Address - Zip Code:49316-7672
Mailing Address - Country:US
Mailing Address - Phone:231-557-2189
Mailing Address - Fax:
Practice Address - Street 1:933 3 MILE RD NW STE 110
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49544-1673
Practice Address - Country:US
Practice Address - Phone:616-785-2619
Practice Address - Fax:616-785-2623
Is Sole Proprietor?:No
Enumeration Date:2012-05-10
Last Update Date:2012-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5502003518225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant