Healthcare Provider Details

I. General information

NPI: 1982931861
Provider Name (Legal Business Name): KELLY JEAN VIRES MOT OTRL
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: KELLY JEAN LANE MOT, OTRL

II. Dates (important events)

Enumeration Date: 11/12/2009
Last Update Date: 08/14/2026
Certification Date: 08/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

52585 DEQUINDRE RD
ROCHESTER HILLS MI
48307-2321
US

IV. Provider business mailing address

1154 RIDGEVIEW CIR
LAKE ORION MI
48362-3452
US

V. Phone/Fax

Practice location:
  • Phone: 248-726-3000
  • Fax:
Mailing address:
  • Phone: 586-383-0594
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number5201008913
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: