=====================================================
General NPI Number Information
=====================================================
NPI Number | 1154960300
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | INDPENDENCE AT HOME PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/04/2020
-----------------------------------------------------
Last Update Date | 01/04/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 541 UNION ST
-----------------------------------------------------
City | NILES
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49120-1536
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 248-435-4606
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 541 UNION ST
-----------------------------------------------------
City | NILES
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49120-1536
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 248-435-4606
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | BRIDGET BENOIT
-----------------------------------------------------
Credential | OTR/L
-----------------------------------------------------
Telephone | 248-425-4606
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261Q00000X
-----------------------------------------------------
Taxonomy Name | Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 261QP2000X
-----------------------------------------------------
Taxonomy Name | Physical Therapy Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 225X00000X
-----------------------------------------------------
Taxonomy Name | Occupational Therapist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------