Basic Information
| Provider Information | |||||||||
| NPI: | 1457747685 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ELLINGER | ||||||||
| FirstName: | JESSICA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | OTR/L CBIS | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | FLUEGEMAN | ||||||||
| OtherFirstName: | JESSICA | ||||||||
| OtherMiddleName: | |||||||||
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| OtherNameSuffix: | |||||||||
| OtherCredential: | OTR/L, CBIS | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 3181 SANDHILL RD | ||||||||
| Address2: | |||||||||
| City: | MASON | ||||||||
| State: | MI | ||||||||
| PostalCode: | 488549425 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5173366060 | ||||||||
| FaxNumber: | 5173366050 | ||||||||
| Practice Location | |||||||||
| Address1: | 3181 SANDHILL RD | ||||||||
| Address2: | |||||||||
| City: | MASON | ||||||||
| State: | MI | ||||||||
| PostalCode: | 488549425 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5173366060 | ||||||||
| FaxNumber: | 5173366050 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/14/2015 | ||||||||
| LastUpdateDate: | 02/08/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225XN1300X | 5201008424 | MI | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | Neurorehabilitation |
ID Information
| ID | Type | State | Issuer | Description | 5201008424 | 01 | MI | OCCUPATIONAL THERAPIST LICENSE | OTHER | 305197 | 01 | NATIONAL BOARD FOR CERTIFICATION IN OCCUPATIONAL THERAPY | OTHER |