=====================================================
General NPI Number Information
=====================================================
NPI Number | 1497270482
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KARA LYNNE VANDERBOON OTR/L
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/10/2017
-----------------------------------------------------
Last Update Date | 03/17/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 25 CONRAN DRIVE
-----------------------------------------------------
City | COOPERSVILLE
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49404
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 616-997-6172
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2250 ELMER DRIVE NE
-----------------------------------------------------
City | GRAND RAPIDS
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49525
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
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 | 5201009654
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------