Provider Demographics
NPI:1285315705
Name:WINFREY, KELLY
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:WINFREY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15860 LINDSAY ST
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48227-1526
Mailing Address - Country:US
Mailing Address - Phone:313-826-9566
Mailing Address - Fax:
Practice Address - Street 1:18940 SCHOOLCRAFT
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48223-2906
Practice Address - Country:US
Practice Address - Phone:248-513-5627
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-07-27
Last Update Date:2023-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty