Healthcare Provider Details

I. General information

NPI: 1205393691
Provider Name (Legal Business Name): NANCY ROSEANN POELSTRA OTR/L
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/21/2019
Last Update Date: 02/21/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4000 N MICHIGAN RD
DIMONDALE MI
48821-9744
US

IV. Provider business mailing address

5556 LAWRENCE CT
PINCKNEY MI
48169-9257
US

V. Phone/Fax

Practice location:
  • Phone: 517-646-6258
  • Fax:
Mailing address:
  • Phone: 586-899-6574
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XP0019X
TaxonomyPhysical Rehabilitation Occupational Therapist
License Number425645
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: