Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225XG0600X | Occupational Therapist - Gerontology |
NPI | 1922577790 |
---|---|
Provider Name | Theresa Marie Lienau |
First Address | Flushing, MI 48433-1474 |
Second Address | Flushing, MI 48433-1474 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 21/11/2018 |
Last Update Date | 21/11/2018 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
1114966983 | (05) | MI |