Healthcare Provider Details

I. General information

NPI: 1003528126
Provider Name (Legal Business Name): SAVANNAH BOLOTTA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/20/2022
Last Update Date: 12/20/2022
Certification Date: 12/20/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

210 TOWN CENTER DR
TROY MI
48084-1774
US

IV. Provider business mailing address

1949 JONATHAN CIR
SHELBY TOWNSHIP MI
48317-3821
US

V. Phone/Fax

Practice location:
  • Phone: 866-812-8896
  • Fax:
Mailing address:
  • Phone: 586-531-9599
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number5202009995
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: