Healthcare Provider Details

I. General information

NPI: 1588767966
Provider Name (Legal Business Name): LYNDA T CUNNINGHAM OTA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/07/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

48208 W GRAND BLVD
DETROIT MI
48208-1105
US

IV. Provider business mailing address

48208 W GRAND BLVD
DETROIT MI
48208-1105
US

V. Phone/Fax

Practice location:
  • Phone: 313-961-3700
  • Fax: 313-961-3769
Mailing address:
  • Phone: 313-961-3700
  • Fax: 313-961-3769

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number5202004534
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: