=====================================================
General NPI Number Information
=====================================================
NPI Number | 1811210321
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CHRIS GROULX COTAL
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/11/2010
-----------------------------------------------------
Last Update Date | 03/11/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 14145 SIMONE DR
-----------------------------------------------------
City | SHELBY TWP.
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48315
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 586-566-6280
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 20178 ELECTRA
-----------------------------------------------------
City | CLINTON TOWNSHIP
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48035
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 224Z00000X
-----------------------------------------------------
Taxonomy Name | Occupational Therapy Assistant
-----------------------------------------------------
License Number | 5202007228
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------