Provider Demographics
NPI:1942604475
Name:HANSEN, KELLY MARIE (MT)
Entity type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:MARIE
Last Name:HANSEN
Suffix:
Gender:F
Credentials:MT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3010 WILSON AVE SW
Mailing Address - Street 2:
Mailing Address - City:GRANDVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:49418-1242
Mailing Address - Country:US
Mailing Address - Phone:616-249-8141
Mailing Address - Fax:616-249-8147
Practice Address - Street 1:3010 WILSON AVE SW
Practice Address - Street 2:
Practice Address - City:GRANDVILLE
Practice Address - State:MI
Practice Address - Zip Code:49418-1242
Practice Address - Country:US
Practice Address - Phone:616-249-8141
Practice Address - Fax:616-249-8147
Is Sole Proprietor?:Yes
Enumeration Date:2014-10-13
Last Update Date:2014-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI7501003433225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist