Provider Demographics
NPI:1215232806
Name:WEIR, KELLY MICHELLE (AT, ATC, PES, CSCS)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:MICHELLE
Last Name:WEIR
Suffix:
Gender:F
Credentials:AT, ATC, PES, CSCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1418 SUNSET DR
Mailing Address - Street 2:
Mailing Address - City:WOLVERINE LAKE
Mailing Address - State:MI
Mailing Address - Zip Code:48390-2348
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:39450 W 12 MILE RD
Practice Address - Street 2:
Practice Address - City:NOVI
Practice Address - State:MI
Practice Address - Zip Code:48377-3600
Practice Address - Country:US
Practice Address - Phone:248-344-2300
Practice Address - Fax:248-344-2301
Is Sole Proprietor?:No
Enumeration Date:2011-01-13
Last Update Date:2021-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI26010002942255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer