Healthcare Provider Details

I. General information

NPI: 1518621135
Provider Name (Legal Business Name): KELLY MCCAMMON PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KELLY DRUDING

II. Dates (important events)

Enumeration Date: 10/29/2021
Last Update Date: 02/27/2024
Certification Date: 02/27/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9817 E US HIGHWAY 36
AVON IN
46123-7954
US

IV. Provider business mailing address

33900 HARPER AVE STE 104
CLINTON TWP MI
48035-4258
US

V. Phone/Fax

Practice location:
  • Phone: 317-860-7677
  • Fax: 317-860-7668
Mailing address:
  • Phone: 586-350-2644
  • Fax: 586-541-3735

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number06001909A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: