Basic Information
| Provider Information | |||||||||
| NPI: | 1932662483 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GRAEBER | ||||||||
| FirstName: | MATTHEW | ||||||||
| MiddleName: | JON | ||||||||
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| Credential: | OTR | ||||||||
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| Mailing Information | |||||||||
| Address1: | 15643 KATHERINE TRL | ||||||||
| Address2: | |||||||||
| City: | MARSHALL | ||||||||
| State: | MI | ||||||||
| PostalCode: | 490689475 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2699863990 | ||||||||
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| Practice Location | |||||||||
| Address1: | 90 N MICHIGAN AVE | ||||||||
| Address2: | |||||||||
| City: | COLDWATER | ||||||||
| State: | MI | ||||||||
| PostalCode: | 490361527 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5172799808 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/11/2019 | ||||||||
| LastUpdateDate: | 06/22/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/22/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225X00000X | 5201006064 | MI | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | 225X00000X | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |
ID Information
| ID | Type | State | Issuer | Description | 5201006064 | 01 | MI | BOARD OF OCCUPATIONAL THERAPISTS | OTHER | 5201006064 | 01 | MI | DEPARTMENT OF LICENSING AND REGULATORY AFFAIRS | OTHER |