Healthcare Provider Details

I. General information

NPI: 1871005264
Provider Name (Legal Business Name): AMBER MICHALCZAK
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/25/2017
Last Update Date: 02/16/2022
Certification Date: 02/16/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3285 MARTIN RD STE 104
COMMERCE TOWNSHIP MI
48390-1601
US

IV. Provider business mailing address

885 N OLD WOODWARD AVE APT 6
BIRMINGHAM MI
48009-1388
US

V. Phone/Fax

Practice location:
  • Phone: 248-684-9610
  • Fax:
Mailing address:
  • Phone: 586-933-6541
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License Number5201009897
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: