Healthcare Provider Details

I. General information

NPI: 1922168988
Provider Name (Legal Business Name): ADELE LOCICERO VITALE OTR
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/11/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

422 CLINTON ST
WYANDOTTE MI
48192-2620
US

IV. Provider business mailing address

422 CLINTON ST
WYANDOTTE MI
48192-2620
US

V. Phone/Fax

Practice location:
  • Phone: 734-284-1578
  • Fax:
Mailing address:
  • Phone: 734-284-1578
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XN1300X
TaxonomyNeurorehabilitation Occupational Therapist
License Number5201005622
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: