Provider Demographics
NPI:1164614665
Name:GRACE, KATHLEEN (MS OTR)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:
Last Name:GRACE
Suffix:
Gender:F
Credentials:MS OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 852
Mailing Address - Street 2:
Mailing Address - City:SOUTH LYON
Mailing Address - State:MI
Mailing Address - Zip Code:48178-0852
Mailing Address - Country:US
Mailing Address - Phone:313-802-6926
Mailing Address - Fax:
Practice Address - Street 1:27525 MARTINDALE RD
Practice Address - Street 2:
Practice Address - City:NEW HUDSON
Practice Address - State:MI
Practice Address - Zip Code:48165-9601
Practice Address - Country:US
Practice Address - Phone:313-802-6926
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-17
Last Update Date:2007-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XN1300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistNeurorehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIP28700001OtherMEDICARE PART B PROVIDER