Healthcare Provider Details

I. General information

NPI: 1669955514
Provider Name (Legal Business Name): CORRINA RAE ANDERSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/06/2018
Last Update Date: 10/17/2023
Certification Date: 10/17/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

220 CHERRY ST SE # 1
GRAND RAPIDS MI
49503-4608
US

IV. Provider business mailing address

6704 N WENTWARD CT
HUDSONVILLE MI
49426-9251
US

V. Phone/Fax

Practice location:
  • Phone: 616-685-4687
  • Fax:
Mailing address:
  • Phone: 906-290-4389
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code225800000X
TaxonomyRecreation Therapist
License Number83895
License Number StateMI
# 3
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number5201013645
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: