Basic Information
| Provider Information | |||||||||
| NPI: | 1801109558 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GRAVES | ||||||||
| FirstName: | KELLIE | ||||||||
| MiddleName: | RENAE | ||||||||
| NamePrefix: | MS. | ||||||||
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| Credential: | OTR/L | ||||||||
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| Mailing Information | |||||||||
| Address1: | 32336 NORFOLK ST | ||||||||
| Address2: | |||||||||
| City: | LIVONIA | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481521513 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2483454193 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3800 PARK EAST DR | ||||||||
| Address2: | |||||||||
| City: | BEACHWOOD | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441224316 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2168314303 | ||||||||
| FaxNumber: | 2168311032 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/23/2010 | ||||||||
| LastUpdateDate: | 07/23/2010 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225X00000X | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |
No ID Information.