Provider Demographics
NPI:1922730514
Name:SPENCER-KELLY, PAMELA A (BSW, LMT)
Entity Type:Individual
Prefix:
First Name:PAMELA
Middle Name:A
Last Name:SPENCER-KELLY
Suffix:
Gender:F
Credentials:BSW, LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3404 ASSUMPTION DR NE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49525-2617
Mailing Address - Country:US
Mailing Address - Phone:616-490-1818
Mailing Address - Fax:
Practice Address - Street 1:3404 ASSUMPTION DR NE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49525-2617
Practice Address - Country:US
Practice Address - Phone:616-490-1818
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-30
Last Update Date:2022-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI7501005338225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist