Healthcare Provider Details

I. General information

NPI: 1104478643
Provider Name (Legal Business Name): KELLI MICHELLE DYE MCLAREN PT DPT SCS CMTPT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/15/2019
Last Update Date: 07/15/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

470 NORTHSIDE CHEROKEE BLVD
CANTON GA
30115-8015
US

IV. Provider business mailing address

4490 INDIAN TRACE DR
ALPHARETTA GA
30004-2584
US

V. Phone/Fax

Practice location:
  • Phone: 678-773-9117
  • Fax:
Mailing address:
  • Phone: 678-773-9117
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2081S0010X
TaxonomySports Medicine (Physical Medicine & Rehabilitation) Physician
License NumberPT010287
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: