Healthcare Provider Details

I. General information

NPI: 1750640801
Provider Name (Legal Business Name): KELLY MARIE WOOD PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/10/2012
Last Update Date: 05/10/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

933 3 MILE RD NW STE 110
GRAND RAPIDS MI
49544-1673
US

IV. Provider business mailing address

3630 COBBLEFIELD CIR SE APT 10
CALEDONIA MI
49316-7672
US

V. Phone/Fax

Practice location:
  • Phone: 616-785-2619
  • Fax: 616-785-2623
Mailing address:
  • Phone: 231-557-2189
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number5502003518
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: