Basic Information
| Provider Information | |||||||||
| NPI: | 1295138014 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KISSELL | ||||||||
| FirstName: | SONDRA | ||||||||
| MiddleName: | LYNN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 20668 HIBMA RD | ||||||||
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| City: | TUSTIN | ||||||||
| State: | MI | ||||||||
| PostalCode: | 496888241 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8142489144 | ||||||||
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| Practice Location | |||||||||
| Address1: | 600 SE 4TH ST | ||||||||
| Address2: | |||||||||
| City: | CLARE | ||||||||
| State: | MI | ||||||||
| PostalCode: | 486179201 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9893867723 | ||||||||
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| ProviderEnumerationDate: | 10/07/2014 | ||||||||
| LastUpdateDate: | 10/07/2014 | ||||||||
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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 | 224Z00000X | 3658528 | MI | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapy Assistant |
No ID Information.