Provider Demographics
NPI:1922434836
Name:KELLY, KRISTIN MARIE (PT)
Entity Type:Individual
Prefix:MRS
First Name:KRISTIN
Middle Name:MARIE
Last Name:KELLY
Suffix:
Gender:F
Credentials:PT
Other - Prefix:MS
Other - First Name:KRISTIN
Other - Middle Name:MARIE
Other - Last Name:KELLY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:8481 HOLLY RD
Mailing Address - Street 2:
Mailing Address - City:GRAND BLANC
Mailing Address - State:MI
Mailing Address - Zip Code:48439-1812
Mailing Address - Country:US
Mailing Address - Phone:810-694-1711
Mailing Address - Fax:
Practice Address - Street 1:8481 HOLLY RD
Practice Address - Street 2:
Practice Address - City:GRAND BLANC
Practice Address - State:MI
Practice Address - Zip Code:48439-1812
Practice Address - Country:US
Practice Address - Phone:810-694-1711
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-09-24
Last Update Date:2013-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501011100225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist