Provider Demographics
NPI:1669885018
Name:BANACH, KELSEY (OTR)
Entity type:Individual
Prefix:
First Name:KELSEY
Middle Name:
Last Name:BANACH
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:68050 HARTWAY RD
Mailing Address - Street 2:
Mailing Address - City:RAY
Mailing Address - State:MI
Mailing Address - Zip Code:48096-1433
Mailing Address - Country:US
Mailing Address - Phone:586-623-2986
Mailing Address - Fax:
Practice Address - Street 1:15063 GRATIOT AVE
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48205-1332
Practice Address - Country:US
Practice Address - Phone:313-372-4065
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-03
Last Update Date:2014-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5201008857225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist