Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225XN1300X | Occupational Therapist - Neurorehabilitation |
NPI | 1164614665 |
---|---|
Provider Name | Kathleen Grace |
First Address | South Lyon, MI 48178-0852 |
Second Address | New Hudson, MI 48165-9601 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 17/08/2007 |
Last Update Date | 17/08/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
P28700001 | MEDICARE PART B PROVIDER (01) | MI |