Provider Demographics
NPI:1902308158
Name:ROSKELLY, KELLI
Entity Type:Individual
Prefix:MRS
First Name:KELLI
Middle Name:
Last Name:ROSKELLY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:159 KERCHEVAL AVE
Mailing Address - Street 2:
Mailing Address - City:GROSSE POINTE FARMS
Mailing Address - State:MI
Mailing Address - Zip Code:48236-3610
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:159 KERCHEVAL AVE
Practice Address - Street 2:
Practice Address - City:GROSSE POINTE FARMS
Practice Address - State:MI
Practice Address - Zip Code:48236-3610
Practice Address - Country:US
Practice Address - Phone:313-640-2200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-05
Last Update Date:2021-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501010005225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist