Healthcare Provider Details

I. General information

NPI: 1386133189
Provider Name (Legal Business Name): SANDRA RUMAN OTRL, CLT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/07/2018
Last Update Date: 04/17/2021
Certification Date: 04/17/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16301 19 MILE RD
CLINTON TWP MI
48038-1104
US

IV. Provider business mailing address

16301 19 MILE RD
CLINTON TWP MI
48038-1104
US

V. Phone/Fax

Practice location:
  • Phone: 586-263-2480
  • Fax: 586-263-2179
Mailing address:
  • Phone: 586-263-2480
  • Fax: 586-263-2179

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number5201000916
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: