Provider Demographics
NPI:1013550052
Name:VAN COPPENOLLE, CHERRELLE
Entity Type:Individual
Prefix:
First Name:CHERRELLE
Middle Name:
Last Name:VAN COPPENOLLE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:650 STRATFORD RD
Mailing Address - Street 2:
Mailing Address - City:FERNDALE
Mailing Address - State:MI
Mailing Address - Zip Code:48220-2369
Mailing Address - Country:US
Mailing Address - Phone:567-208-6045
Mailing Address - Fax:
Practice Address - Street 1:650 STRATFORD RD
Practice Address - Street 2:
Practice Address - City:FERNDALE
Practice Address - State:MI
Practice Address - Zip Code:48220-2369
Practice Address - Country:US
Practice Address - Phone:567-208-6045
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-22
Last Update Date:2019-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5201010430225XP0019X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0019XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPhysical Rehabilitation