Provider Demographics
NPI:1356551824
Name:MAHLA, KELLY JEAN (LLP, PTA)
Entity type:Individual
Prefix:MISS
First Name:KELLY
Middle Name:JEAN
Last Name:MAHLA
Suffix:
Gender:F
Credentials:LLP, PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:55753 SERENE DR
Mailing Address - Street 2:
Mailing Address - City:MACOMB
Mailing Address - State:MI
Mailing Address - Zip Code:48042-6164
Mailing Address - Country:US
Mailing Address - Phone:586-216-3815
Mailing Address - Fax:
Practice Address - Street 1:55753 SERENE DR
Practice Address - Street 2:
Practice Address - City:MACOMB
Practice Address - State:MI
Practice Address - Zip Code:48042-6164
Practice Address - Country:US
Practice Address - Phone:586-216-3815
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-23
Last Update Date:2012-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301013552103TC0700X
225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical