Provider Demographics
NPI:1649481094
Name:KOHLER, KELLY COLLEEN (CMT, LMT)
Entity type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:COLLEEN
Last Name:KOHLER
Suffix:
Gender:F
Credentials:CMT, LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:515 BAY ST
Mailing Address - Street 2:
Mailing Address - City:TRAVERSE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49684-2283
Mailing Address - Country:US
Mailing Address - Phone:231-649-6258
Mailing Address - Fax:231-421-5478
Practice Address - Street 1:515 BAY ST
Practice Address - Street 2:
Practice Address - City:TRAVERSE CITY
Practice Address - State:MI
Practice Address - Zip Code:49684-2283
Practice Address - Country:US
Practice Address - Phone:231-421-5477
Practice Address - Fax:231-421-5478
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-25
Last Update Date:2010-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN0265225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist