Basic Information
Provider Information | |||||||||
NPI: | 1003000605 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | FREEMAN | ||||||||
FirstName: | DIANE | ||||||||
MiddleName: | ELIZABETH | ||||||||
NamePrefix: | MRS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | OTR | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | DEAVER | ||||||||
OtherFirstName: | DIANE | ||||||||
OtherMiddleName: | ELIZABETH | ||||||||
OtherNamePrefix: | MISS | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | OTR | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 11035 E RICHFIELD RD | ||||||||
Address2: |   | ||||||||
City: | DAVISON | ||||||||
State: | MI | ||||||||
PostalCode: | 484238517 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8106542422 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 11035 E RICHFIELD RD | ||||||||
Address2: |   | ||||||||
City: | DAVISON | ||||||||
State: | MI | ||||||||
PostalCode: | 484238517 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8106542422 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/28/2007 | ||||||||
LastUpdateDate: | 03/20/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 03/20/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | 5201003946 | MI | N |   | Other Service Providers | Specialist |   | 225XN1300X | 5201003946 | MI | Y |   | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | Neurorehabilitation |
No ID Information.