Healthcare Provider Details

I. General information

NPI: 1659104115
Provider Name (Legal Business Name): CHILDRENS THERAPY SHOP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/21/2024
Last Update Date: 08/19/2026
Certification Date: 08/19/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

24410 MIDDLEBELT RD.
NEW BOSTON MI
48164-9487
US

IV. Provider business mailing address

24410 MIDDLEBELT RD
NEW BOSTON MI
48164-9487
US

V. Phone/Fax

Practice location:
  • Phone: 734-252-9167
  • Fax: 734-252-9958
Mailing address:
  • Phone: 734-664-8180
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number
License Number State

VIII. Authorized Official

Name: KERIELLE LINNE SMITH
Title or Position: OWNER/OCCUPATIONAL THERAPIST
Credential: OTR/L, MS, MA
Phone: 734-252-9958