Healthcare Provider Details

I. General information

NPI: 1396248597
Provider Name (Legal Business Name): LORI LEE BULTINCK OTR
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/14/2018
Last Update Date: 03/14/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4118 KALAMAZOO AVE SE
GRAND RAPIDS MI
49508-3605
US

IV. Provider business mailing address

2497 BLUEWATER CT SW
GRANDVILLE MI
49418-1150
US

V. Phone/Fax

Practice location:
  • Phone: 616-455-7300
  • Fax:
Mailing address:
  • Phone: 616-291-7301
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XP0019X
TaxonomyPhysical Rehabilitation Occupational Therapist
License Number5201006053
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: