Basic Information
| Provider Information | |||||||||
| NPI: | 1750640801 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WOOD | ||||||||
| FirstName: | KELLY | ||||||||
| MiddleName: | MARIE | ||||||||
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| Credential: | PTA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3630 COBBLEFIELD CIR SE APT 10 | ||||||||
| Address2: | |||||||||
| City: | CALEDONIA | ||||||||
| State: | MI | ||||||||
| PostalCode: | 493167672 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2315572189 | ||||||||
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| Practice Location | |||||||||
| Address1: | 933 3 MILE RD NW STE 110 | ||||||||
| Address2: | |||||||||
| City: | GRAND RAPIDS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 495441673 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6167852619 | ||||||||
| FaxNumber: | 6167852623 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/10/2012 | ||||||||
| LastUpdateDate: | 05/10/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225200000X | 5502003518 | MI | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapy Assistant |
No ID Information.