Provider Demographics
NPI:1295418234
Name:WODARSKI, KELSEY (CTRS, MA)
Entity type:Individual
Prefix:
First Name:KELSEY
Middle Name:
Last Name:WODARSKI
Suffix:
Gender:F
Credentials:CTRS, MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3588 PLYMOUTH RD # 393
Mailing Address - Street 2:
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48105-2603
Mailing Address - Country:US
Mailing Address - Phone:734-352-3543
Mailing Address - Fax:
Practice Address - Street 1:7794 PAINT CREEK DR
Practice Address - Street 2:
Practice Address - City:YPSILANTI
Practice Address - State:MI
Practice Address - Zip Code:48197-6139
Practice Address - Country:US
Practice Address - Phone:734-352-3543
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-08
Last Update Date:2023-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH64544225800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225800000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRecreation Therapist