MEDICARE: KELSEY PETERSON

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225X00000X	Occupational Therapist	5201013406	MI
2	106S00000X	Behavior Technician

General Provider Information

NPI Number	:	1730604802
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KELSEY PETERSON

Provider Business Mailing Address
First Line	:	41521 W 11 MILE RD
Second Line	:
City	:	NOVI
State	:	MI
Zip	:	48375-1803
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	5460 W ROLLING HILLS DR
Second Line	:
City	:	BRIDGEPORT
State	:	MI
Zip	:	48722-9668
Country	:	US
Telephone Number	:	989-272-4500
Fax Number	:	989-272-4501

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/09/2017
Last Update Date	:	12/08/2025

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Directions to “ KELSEY PETERSON ” Practice Location

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