Provider Demographics
NPI:1649791237
Name:DAVIS, KELSIE MARIE (DPT)
Entity type:Individual
Prefix:
First Name:KELSIE
Middle Name:MARIE
Last Name:DAVIS
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:KELSIE
Other - Middle Name:MARIE
Other - Last Name:COLLINS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:790 REMINGTON BLVD
Mailing Address - Street 2:
Mailing Address - City:BOLINGBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60440-4909
Mailing Address - Country:US
Mailing Address - Phone:630-296-2222
Mailing Address - Fax:630-759-9510
Practice Address - Street 1:4950 S BALDWIN RD
Practice Address - Street 2:
Practice Address - City:LAKE ORION
Practice Address - State:MI
Practice Address - Zip Code:48359-2116
Practice Address - Country:US
Practice Address - Phone:248-409-0576
Practice Address - Fax:248-209-7083
Is Sole Proprietor?:No
Enumeration Date:2017-07-05
Last Update Date:2019-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501018243225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist