Provider Demographics
NPI:1033511860
Name:KELLY, ALEXIS (OTR-L)
Entity type:Individual
Prefix:
First Name:ALEXIS
Middle Name:
Last Name:KELLY
Suffix:
Gender:F
Credentials:OTR-L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:801 HAZEN ST
Mailing Address - Street 2:
Mailing Address - City:PAW PAW
Mailing Address - State:MI
Mailing Address - Zip Code:49079-2008
Mailing Address - Country:US
Mailing Address - Phone:269-655-3334
Mailing Address - Fax:269-657-6523
Practice Address - Street 1:801 HAZEN ST
Practice Address - Street 2:
Practice Address - City:PAW PAW
Practice Address - State:MI
Practice Address - Zip Code:49079-2008
Practice Address - Country:US
Practice Address - Phone:269-655-3334
Practice Address - Fax:269-657-6523
Is Sole Proprietor?:No
Enumeration Date:2014-09-24
Last Update Date:2019-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5201010720225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist