Healthcare Provider Details

I. General information

NPI: 1053954321
Provider Name (Legal Business Name): KIMBERLY RENEE RAYMOND OTRL
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/19/2019
Last Update Date: 10/19/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

610 W ELM AVE
MONROE MI
48162-7909
US

IV. Provider business mailing address

15485 BIRCHDALE CIR
MONROE MI
48161-4548
US

V. Phone/Fax

Practice location:
  • Phone: 734-241-3660
  • Fax:
Mailing address:
  • Phone: 734-497-7436
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number5201010711
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: