Provider Demographics
NPI:1962609834
Name:KELLY-ROBERTS, REGINA (DC)
Entity type:Individual
Prefix:DR
First Name:REGINA
Middle Name:
Last Name:KELLY-ROBERTS
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:32 S SQUIRREL RD
Mailing Address - Street 2:
Mailing Address - City:AUBURN HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48326-3287
Mailing Address - Country:US
Mailing Address - Phone:248-289-6870
Mailing Address - Fax:248-289-6871
Practice Address - Street 1:3396 E WEST MAPLE RD
Practice Address - Street 2:
Practice Address - City:COMMERCE TWP
Practice Address - State:MI
Practice Address - Zip Code:48390-3807
Practice Address - Country:US
Practice Address - Phone:248-960-3599
Practice Address - Fax:248-960-3599
Is Sole Proprietor?:No
Enumeration Date:2007-07-02
Last Update Date:2024-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2301008876111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI12501Medicare ID - Type Unspecified