Provider Demographics
NPI:1063870418
Name:WALLACE, KELSEY (LMT)
Entity type:Individual
Prefix:
First Name:KELSEY
Middle Name:
Last Name:WALLACE
Suffix:
Gender:
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16500 JOY RD # 258
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48228-0632
Mailing Address - Country:US
Mailing Address - Phone:248-417-5352
Mailing Address - Fax:888-793-5313
Practice Address - Street 1:16500 JOY RD # 258
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48228-0632
Practice Address - Country:US
Practice Address - Phone:248-417-5352
Practice Address - Fax:888-793-5313
Is Sole Proprietor?:Yes
Enumeration Date:2016-02-01
Last Update Date:2025-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI7501007544225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist