Basic Information
| Provider Information | |||||||||
| NPI: | 1013229467 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LARUE | ||||||||
| FirstName: | JENNIFER | ||||||||
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| Credential: | OTRL | ||||||||
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| Mailing Information | |||||||||
| Address1: | 138 W HIGHLAND RD # RS | ||||||||
| Address2: | SUITE 500-600 | ||||||||
| City: | HOWELL | ||||||||
| State: | MI | ||||||||
| PostalCode: | 488432168 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5173764831 | ||||||||
| FaxNumber: | 5173764833 | ||||||||
| Practice Location | |||||||||
| Address1: | 138 W HIGHLAND RD # RS | ||||||||
| Address2: | SUITE 500-600 | ||||||||
| City: | HOWELL | ||||||||
| State: | MI | ||||||||
| PostalCode: | 488432168 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5173764831 | ||||||||
| FaxNumber: | 5173764833 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/13/2010 | ||||||||
| LastUpdateDate: | 01/31/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225XP0200X | 5201006346 | MI | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 5201006346 | 01 | MI | OCCUPATIONAL THERAPIST LICENSE | OTHER |