=====================================================
General NPI Number Information
=====================================================
NPI Number | 1780975573
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ELLEN CHRISTINE HERLACHE ED.D, MA, OTRL
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/27/2011
-----------------------------------------------------
Last Update Date | 04/27/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5161 CARDINAL PARK DR
-----------------------------------------------------
City | SAGINAW
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48604
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 989-249-8853
-----------------------------------------------------
Fax | 989-249-8842
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 5649
-----------------------------------------------------
City | SAGINAW
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48603-0649
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 989-249-8853
-----------------------------------------------------
Fax | 989-249-8842
-----------------------------------------------------
=====================================================
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 | L1992087
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------