Provider Demographics
NPI:1316990195
Name:STEPANEK, KELLY JO (OTR,CHT)
Entity type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:JO
Last Name:STEPANEK
Suffix:
Gender:F
Credentials:OTR,CHT
Other - Prefix:MS
Other - First Name:KELLY
Other - Middle Name:JO
Other - Last Name:BRYANT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OTR,CHT
Mailing Address - Street 1:8636 24TH AVE
Mailing Address - Street 2:
Mailing Address - City:JENISON
Mailing Address - State:MI
Mailing Address - Zip Code:49428-9543
Mailing Address - Country:US
Mailing Address - Phone:616-745-4722
Mailing Address - Fax:
Practice Address - Street 1:245 CHERRY ST SE
Practice Address - Street 2:SUITE 308
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49503-4607
Practice Address - Country:US
Practice Address - Phone:616-459-4131
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-19
Last Update Date:2014-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5201003107174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist