Provider Demographics
NPI:1386075257
Name:KELLY, MEGHAN (ATC)
Entity type:Individual
Prefix:
First Name:MEGHAN
Middle Name:
Last Name:KELLY
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:103 W MICHIGAN AVE
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:MI
Mailing Address - Zip Code:49236-9577
Mailing Address - Country:US
Mailing Address - Phone:517-456-5080
Mailing Address - Fax:517-456-5149
Practice Address - Street 1:103 W MICHIGAN AVE
Practice Address - Street 2:
Practice Address - City:CLINTON
Practice Address - State:MI
Practice Address - Zip Code:49236-9577
Practice Address - Country:US
Practice Address - Phone:517-456-5080
Practice Address - Fax:517-456-5149
Is Sole Proprietor?:No
Enumeration Date:2013-12-03
Last Update Date:2013-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI26010000972255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer