Healthcare Provider Details

I. General information

NPI: 1831457142
Provider Name (Legal Business Name): KINETIC KIDS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/25/2012
Last Update Date: 04/25/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

540 EAST MILHAM
PORTAGE MI
49002
US

IV. Provider business mailing address

540 EAST MILHAM
PORTAGE MI
49002
US

V. Phone/Fax

Practice location:
  • Phone: 269-381-1880
  • Fax: 269-381-1850
Mailing address:
  • Phone: 269-381-1880
  • Fax: 269-381-1850

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License Number5201004171
License Number StateMI

VIII. Authorized Official

Name: MS. KAREN SUE GALLOWAY
Title or Position: CEO
Credential: OTR/L
Phone: 269-381-1880