Healthcare Provider Details

I. General information

NPI: 1174645147
Provider Name (Legal Business Name): ANDREA MARIE KUNKEL C.T.R.S.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/03/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

34647 SHOREWOOD ST
CHESTERFIELD MI
48047-2022
US

IV. Provider business mailing address

34647 SHOREWOOD ST
CHESTERFIELD MI
48047-2022
US

V. Phone/Fax

Practice location:
  • Phone: 810-278-6067
  • Fax:
Mailing address:
  • Phone: 810-278-6067
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225800000X
TaxonomyRecreation Therapist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: