Healthcare Provider Details

I. General information

NPI: 1477041432
Provider Name (Legal Business Name): ATHENA ISIS ANTEAU OTR/L, CHT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/25/2018
Last Update Date: 04/02/2021
Certification Date: 04/02/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1201 E MICHIGAN AVE STE 320
JACKSON MI
49201-1854
US

IV. Provider business mailing address

8041 FAIRVIEW CT
JACKSON MI
49201-9242
US

V. Phone/Fax

Practice location:
  • Phone: 517-205-7633
  • Fax: 517-205-7634
Mailing address:
  • Phone: 734-645-7058
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XH1200X
TaxonomyHand Occupational Therapist
License Number5201005217
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: