Provider Demographics
NPI:1154698561
Name:DETWILER, KELLI MARIE (LPTA)
Entity type:Individual
Prefix:MRS
First Name:KELLI
Middle Name:MARIE
Last Name:DETWILER
Suffix:
Gender:F
Credentials:LPTA
Other - Prefix:MISS
Other - First Name:KELLI
Other - Middle Name:MARIE
Other - Last Name:HOLLAND
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2194 E BOATFIELD AVE
Mailing Address - Street 2:
Mailing Address - City:BURTON
Mailing Address - State:MI
Mailing Address - Zip Code:48529-1716
Mailing Address - Country:US
Mailing Address - Phone:810-835-6114
Mailing Address - Fax:
Practice Address - Street 1:2194 E BOATFIELD AVE
Practice Address - Street 2:
Practice Address - City:BURTON
Practice Address - State:MI
Practice Address - Zip Code:48529-1716
Practice Address - Country:US
Practice Address - Phone:810-835-6114
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-11-30
Last Update Date:2025-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant