Basic Information
Provider Information | |||||||||
NPI: | 1689078180 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | MARTIN | ||||||||
FirstName: | JAMIE | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | KAZMIRZACK | ||||||||
OtherFirstName: | JAMIE | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 33900 HARPER AVE | ||||||||
Address2: | SUITE 104 | ||||||||
City: | CLINTON TOWNSHIP | ||||||||
State: | MI | ||||||||
PostalCode: | 480354258 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5864169100 | ||||||||
FaxNumber: | 5864169103 | ||||||||
Practice Location | |||||||||
Address1: | 5141 OAKMAN BLVD | ||||||||
Address2: | STE D | ||||||||
City: | DEARBORN | ||||||||
State: | MI | ||||||||
PostalCode: | 481263763 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3133598200 | ||||||||
FaxNumber: | 3133228033 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/14/2014 | ||||||||
LastUpdateDate: | 03/15/2016 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225X00000X | 5201007498 | MI | Y |   | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |   |
No ID Information.