Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225X00000X | Occupational Therapist | 5201010533 | MI |
NPI | 1003458423 |
---|---|
Provider Name | Kelly Lynn Ouellette |
First Address | Grand Rapids, MI 49503-2560 |
Second Address | Grand Haven, MI 49417-8696 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 17/10/2019 |
Last Update Date | 17/10/2019 |