Healthcare Provider Details

I. General information

NPI: 1598372187
Provider Name (Legal Business Name): MARYKELLY WALLACE MOTR/L
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/28/2020
Last Update Date: 02/14/2025
Certification Date: 02/14/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 PARKLANE BLVD STE 200
DEARBORN MI
48126-4221
US

IV. Provider business mailing address

27085 GRATIOT AVE STE 101
ROSEVILLE MI
48066-2984
US

V. Phone/Fax

Practice location:
  • Phone: 313-846-2606
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number5201010849
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: