Healthcare Provider Details

I. General information

NPI: 1265064547
Provider Name (Legal Business Name): EMMA ROSE HOSTETLER OTR/L
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/05/2020
Last Update Date: 04/24/2025
Certification Date: 04/24/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5258 PLAINFIELD AVE NE STE A
GRAND RAPIDS MI
49525-1092
US

IV. Provider business mailing address

5258 PLAINFIELD AVE NE STE A
GRAND RAPIDS MI
49525-1092
US

V. Phone/Fax

Practice location:
  • Phone: 616-466-4068
  • Fax:
Mailing address:
  • Phone: 616-466-4068
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License Number5201010669
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: