=====================================================
General NPI Number Information
=====================================================
NPI Number | 1881391571
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SUSAN MARIE CLEGHORN DROT
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/13/2023
-----------------------------------------------------
Last Update Date | 02/13/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6645 LORNE DR
-----------------------------------------------------
City | PENTWATER
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49449-9610
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 616-402-9115
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6645 LORNE DR
-----------------------------------------------------
City | PENTWATER
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49449-9610
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 616-402-9115
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225XE0001X
-----------------------------------------------------
Taxonomy Name | Environmental Modification Occupational Therapist
-----------------------------------------------------
License Number | 5201006107
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------