Healthcare Provider Details

I. General information

NPI: 1063344547
Provider Name (Legal Business Name): KELLIE HIERL
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/01/2026
Last Update Date: 06/01/2026
Certification Date: 06/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5333 N PORT WASHINGTON RD STE B
GLENDALE WI
53217-4914
US

IV. Provider business mailing address

33900 HARPER AVE STE 104
CLINTON TWP MI
48035-4258
US

V. Phone/Fax

Practice location:
  • Phone: 414-716-1770
  • Fax: 414-716-1772
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number17748-24
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: