Provider Demographics
NPI:1720311962
Name:GROTH, KELLY RIESTERER
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:RIESTERER
Last Name:GROTH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:LYNN
Other - Last Name:RIESTERER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:33900 HARPER AVE
Mailing Address - Street 2:SUITE 104
Mailing Address - City:CLINTON TOWNSHIP
Mailing Address - State:MI
Mailing Address - Zip Code:48035-4258
Mailing Address - Country:US
Mailing Address - Phone:586-416-9100
Mailing Address - Fax:586-416-9103
Practice Address - Street 1:32934 WOODWARD AVE
Practice Address - Street 2:
Practice Address - City:ROYAL OAK
Practice Address - State:MI
Practice Address - Zip Code:48073-0957
Practice Address - Country:US
Practice Address - Phone:248-554-9201
Practice Address - Fax:248-554-9202
Is Sole Proprietor?:Yes
Enumeration Date:2009-09-04
Last Update Date:2024-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501014636225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist