Healthcare Provider Details

I. General information

NPI: 1306357561
Provider Name (Legal Business Name): MARY THERESE OLBROT OTRL
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/16/2017
Last Update Date: 10/16/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5146 BURNING TREE RD
KALAMAZOO MI
49009-3804
US

IV. Provider business mailing address

5146 BURNING TREE RD
KALAMAZOO MI
49009-3804
US

V. Phone/Fax

Practice location:
  • Phone: 269-615-5297
  • Fax:
Mailing address:
  • Phone: 269-377-5506
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number5201004121
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: