Healthcare Provider Details

I. General information

NPI: 1720393515
Provider Name (Legal Business Name): KELLY DENISE MCLEAN MT, RMT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/17/2010
Last Update Date: 02/03/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7070 AUSTRIAN PINE WAY #4
PORTAGE MI
49024-3972
US

IV. Provider business mailing address

7070 AUSTRIAN PINE WAY #4
PORTAGE MI
49024-3972
US

V. Phone/Fax

Practice location:
  • Phone: 269-744-2107
  • Fax:
Mailing address:
  • Phone: 269-744-2107
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: