Provider Demographics
NPI:1114201449
Name:DIRKSE, ELISE RENEE (OTR/L)
Entity Type:Individual
Prefix:MRS
First Name:ELISE
Middle Name:RENEE
Last Name:DIRKSE
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1074 28TH AVE
Mailing Address - Street 2:
Mailing Address - City:HUDSONVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:49426-9630
Mailing Address - Country:US
Mailing Address - Phone:616-896-6484
Mailing Address - Fax:
Practice Address - Street 1:7086 8TH AVE
Practice Address - Street 2:
Practice Address - City:JENISON
Practice Address - State:MI
Practice Address - Zip Code:49428-9352
Practice Address - Country:US
Practice Address - Phone:616-667-9551
Practice Address - Fax:616-667-9552
Is Sole Proprietor?:No
Enumeration Date:2011-10-05
Last Update Date:2011-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5201000987225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist