Healthcare Provider Details

I. General information

NPI: 1225945439
Provider Name (Legal Business Name): KALYNNE MARIE ELLIOTT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/25/2026
Last Update Date: 08/25/2026
Certification Date: 08/25/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

62445 SHIMMEL RD
CENTREVILLE MI
49032-9527
US

IV. Provider business mailing address

11992 F DR S
CERESCO MI
49033-8708
US

V. Phone/Fax

Practice location:
  • Phone: 269-467-5400
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number5502004912
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: