Healthcare Provider Details

I. General information

NPI: 1669118162
Provider Name (Legal Business Name): MADDISON MAREE MENNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/07/2022
Last Update Date: 05/07/2022
Certification Date: 05/06/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18500 VAN HORN RD
WOODHAVEN MI
48183-3803
US

IV. Provider business mailing address

351 TRUAX ST
TRENTON MI
48183-2120
US

V. Phone/Fax

Practice location:
  • Phone: 734-676-7575
  • Fax:
Mailing address:
  • Phone: 734-931-2300
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number5201012961
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code225XH1200X
TaxonomyHand Occupational Therapist
License Number5201012961
License Number StateMI
# 3
Primary TaxonomyN
Taxonomy Code225XH1300X
TaxonomyHuman Factors Occupational Therapist
License Number5201012961
License Number StateMI
# 4
Primary TaxonomyN
Taxonomy Code225XN1300X
TaxonomyNeurorehabilitation Occupational Therapist
License Number5201012961
License Number StateMI
# 5
Primary TaxonomyN
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License Number5201012961
License Number StateMI
# 6
Primary TaxonomyN
Taxonomy Code225XR0403X
TaxonomyDriving and Community Mobility Occupational Therapist
License Number5201012961
License Number StateMI
# 7
Primary TaxonomyN
Taxonomy Code225XG0600X
TaxonomyGerontology Occupational Therapist
License Number5201012961
License Number StateMI
# 8
Primary TaxonomyN
Taxonomy Code225XM0800X
TaxonomyMental Health Occupational Therapist
License Number5201012961
License Number StateMI
# 9
Primary TaxonomyN
Taxonomy Code225XP0019X
TaxonomyPhysical Rehabilitation Occupational Therapist
License Number5201012961
License Number StateMI
# 10
Primary TaxonomyN
Taxonomy Code225XE0001X
TaxonomyEnvironmental Modification Occupational Therapist
License Number5201012961
License Number StateMI
# 11
Primary TaxonomyN
Taxonomy Code225XF0002X
TaxonomyFeeding, Eating & Swallowing Occupational Therapist
License Number5201012961
License Number StateMI
# 12
Primary TaxonomyN
Taxonomy Code225XL0004X
TaxonomyLow Vision Occupational Therapist
License Number5201012961
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: