Healthcare Provider Details

I. General information

NPI: 1245879204
Provider Name (Legal Business Name): REGAN KELLEY OTR/L
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/23/2019
Last Update Date: 03/24/2025
Certification Date: 03/24/2025
Deactivation Date: 03/07/2023
Reactivation Date: 05/25/2023

III. Provider practice location address

2922 FULLER AVE NE STE 105
GRAND RAPIDS MI
49505-3459
US

IV. Provider business mailing address

2922 FULLER AVE NE STE 105
GRAND RAPIDS MI
49505-3459
US

V. Phone/Fax

Practice location:
  • Phone: 616-327-6191
  • Fax: 616-333-4928
Mailing address:
  • Phone: 616-327-6191
  • Fax: 616-333-4928

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License Number5201013256
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: