Healthcare Provider Details

I. General information

NPI: 1154960300
Provider Name (Legal Business Name): INDPENDENCE AT HOME PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/04/2020
Last Update Date: 01/04/2020
Certification Date: 01/04/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

541 UNION ST
NILES MI
49120-1536
US

IV. Provider business mailing address

541 UNION ST
NILES MI
49120-1536
US

V. Phone/Fax

Practice location:
  • Phone: 248-435-4606
  • Fax:
Mailing address:
  • Phone: 248-435-4606
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: BRIDGET BENOIT
Title or Position: OWNER
Credential: OTR/L
Phone: 248-425-4606