Basic Information
| Provider Information | |||||||||
| NPI: | 1679136147 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JORAE | ||||||||
| FirstName: | MONIQUE | ||||||||
| MiddleName: | RENEE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7227 N WELLING RD | ||||||||
| Address2: | |||||||||
| City: | SAINT JOHNS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 488799475 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5178197469 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2378 WOODLAKE DR STE 280 | ||||||||
| Address2: | |||||||||
| City: | OKEMOS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 488646016 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5177060421 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/19/2019 | ||||||||
| LastUpdateDate: | 04/19/2019 | ||||||||
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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 | 225X00000X | 5201010542 | MI | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |
No ID Information.