Provider Demographics
NPI:1114343068
Name:CARLISLE, CORTNEY
Entity Type:Individual
Prefix:
First Name:CORTNEY
Middle Name:
Last Name:CARLISLE
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 1:1460 HIDDEN CREEK CIRCLE DR NE APT C
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49505-5472
Mailing Address - Country:US
Mailing Address - Phone:218-929-9595
Mailing Address - Fax:
Practice Address - Street 1:9809 CHERRY VALLEY AVE SE STE D
Practice Address - Street 2:
Practice Address - City:CALEDONIA
Practice Address - State:MI
Practice Address - Zip Code:49316-9592
Practice Address - Country:US
Practice Address - Phone:269-223-7786
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-03-14
Last Update Date:2018-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5201010171225X00000X
SC4261225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist