Provider Demographics
NPI:1902002298
Name:BOUSSON, KELLY RENE (MS,OTR)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:RENE
Last Name:BOUSSON
Suffix:
Gender:F
Credentials:MS,OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:809 E FILER ST
Mailing Address - Street 2:LUDINGTON
Mailing Address - City:LUDINGTON
Mailing Address - State:MI
Mailing Address - Zip Code:49431-2210
Mailing Address - Country:US
Mailing Address - Phone:231-233-3272
Mailing Address - Fax:
Practice Address - Street 1:1080 E STERNBERG RD
Practice Address - Street 2:MUSKEGON
Practice Address - City:MUSKEGON
Practice Address - State:MI
Practice Address - Zip Code:49444-8796
Practice Address - Country:US
Practice Address - Phone:231-799-2200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5201006679225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist