=====================================================
General NPI Number Information
=====================================================
NPI Number | 1437699121
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CAROLYNN ELIZABETH GRAHAM O.T.R.L.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/01/2017
-----------------------------------------------------
Last Update Date | 03/01/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 348 LONG RAPIDS PLZ
-----------------------------------------------------
City | ALPENA
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49707-1374
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 989-358-8086
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6417 CHURCH ST
-----------------------------------------------------
City | CASS CITY
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48726-1115
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 989-657-1501
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225X00000X
-----------------------------------------------------
Taxonomy Name | Occupational Therapist
-----------------------------------------------------
License Number | 5201009735
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------