Provider Demographics
NPI:1477437796
Name:KELLY, STACY (LMT)
Entity type:Individual
Prefix:MRS
First Name:STACY
Middle Name:
Last Name:KELLY
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2350 WASHTENAW AVE STE 24
Mailing Address - Street 2:
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48104-4524
Mailing Address - Country:US
Mailing Address - Phone:734-985-0324
Mailing Address - Fax:
Practice Address - Street 1:2350 WASHTENAW AVE STE 24
Practice Address - Street 2:
Practice Address - City:ANN ARBOR
Practice Address - State:MI
Practice Address - Zip Code:48104-4524
Practice Address - Country:US
Practice Address - Phone:734-985-0324
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-07-31
Last Update Date:2025-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI7501006400225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist