Healthcare Provider Details

I. General information

NPI: 1790369965
Provider Name (Legal Business Name): BETH ELAINE KOCIBA OTR/L
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: BETH ELAINE ESCHKER OTR/L

II. Dates (important events)

Enumeration Date: 05/12/2021
Last Update Date: 05/12/2021
Certification Date: 05/08/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5700 WATER TOWER PL
CLARKSTON MI
48346-2668
US

IV. Provider business mailing address

1390 COURTNEY CT
HARTLAND MI
48353-3460
US

V. Phone/Fax

Practice location:
  • Phone: 248-625-0500
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XP0019X
TaxonomyPhysical Rehabilitation Occupational Therapist
License Number5201003517
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: