Provider Demographics
NPI:1013413939
Name:CARMONA, BRIAN (OTRL)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:
Last Name:CARMONA
Suffix:
Gender:M
Credentials:OTRL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1470 BUD AVE
Mailing Address - Street 2:
Mailing Address - City:YPSILANTI
Mailing Address - State:MI
Mailing Address - Zip Code:48198-3309
Mailing Address - Country:US
Mailing Address - Phone:937-307-4788
Mailing Address - Fax:
Practice Address - Street 1:700 STEWART RD
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:MI
Practice Address - Zip Code:48162-5304
Practice Address - Country:US
Practice Address - Phone:734-240-1820
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-30
Last Update Date:2018-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5201010045225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist