Healthcare Provider Details

I. General information

NPI: 1578909271
Provider Name (Legal Business Name): MRS. ANDREA MARIE-GIMBOSA CHILDERS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: ANDREA MARIE-GIMBOSA MAITLAND M.O.T., O.T.R.L.,

II. Dates (important events)

Enumeration Date: 05/21/2013
Last Update Date: 05/21/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 STEPHENSON HWY
TROY MI
48083-1110
US

IV. Provider business mailing address

1604 WITHERBEE DR
TROY MI
48084-2684
US

V. Phone/Fax

Practice location:
  • Phone: 248-616-0950
  • Fax: 734-893-3154
Mailing address:
  • Phone: 586-491-4430
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number5201007137
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code225XN1300X
TaxonomyNeurorehabilitation Occupational Therapist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: