Healthcare Provider Details

I. General information

NPI: 1972004729
Provider Name (Legal Business Name): TAMMY JO KRETOWICZ
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/27/2018
Last Update Date: 02/27/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2589 44TH ST SE
KENTWOOD MI
49512-3877
US

IV. Provider business mailing address

1328 RICHFIELD CT SW
BYRON CENTER MI
49315-9493
US

V. Phone/Fax

Practice location:
  • Phone: 616-643-2564
  • Fax:
Mailing address:
  • Phone: 616-914-4039
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number5202007173
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: