Provider Demographics
NPI:1699916049
Name:KORCH, KELLEY LYN
Entity type:Individual
Prefix:
First Name:KELLEY
Middle Name:LYN
Last Name:KORCH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KELLEY
Other - Middle Name:LYN
Other - Last Name:URBIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4419 ELDERBERRY DR
Mailing Address - Street 2:
Mailing Address - City:BRIGHTON
Mailing Address - State:MI
Mailing Address - Zip Code:48114-8621
Mailing Address - Country:US
Mailing Address - Phone:810-599-1840
Mailing Address - Fax:
Practice Address - Street 1:5061 VILLAGE COMMONS DR
Practice Address - Street 2:
Practice Address - City:WEST BLOOMFIELD
Practice Address - State:MI
Practice Address - Zip Code:48322-3382
Practice Address - Country:US
Practice Address - Phone:248-804-3426
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-03-16
Last Update Date:2009-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5201002047225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist