Healthcare Provider Details

I. General information

NPI: 1235700477
Provider Name (Legal Business Name): ESSENTIAL SKILLS OCCUPATIONAL THERAPY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/08/2021
Last Update Date: 07/08/2021
Certification Date: 07/08/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12211 PATTON RD
GRAND RAPIDS OH
43522-9640
US

IV. Provider business mailing address

12211 PATTON RD
GRAND RAPIDS OH
43522-9640
US

V. Phone/Fax

Practice location:
  • Phone: 517-918-9205
  • Fax:
Mailing address:
  • Phone: 517-918-9205
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number
License Number State

VIII. Authorized Official

Name: STACEY MILES
Title or Position: OCCUPATIONAL THERAPIST
Credential: OTR/L
Phone: 517-918-9205