Provider Demographics
NPI:1184816027
Name:TEBBUTT, KRISTEN (MS OTR/L)
Entity Type:Individual
Prefix:
First Name:KRISTEN
Middle Name:
Last Name:TEBBUTT
Suffix:
Gender:F
Credentials:MS OTR/L
Other - Prefix:
Other - First Name:KRISTEN
Other - Middle Name:MICHELE
Other - Last Name:PETRONIO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4904 CARLSON PARK DR
Mailing Address - Street 2:
Mailing Address - City:TROY
Mailing Address - State:MI
Mailing Address - Zip Code:48098-7102
Mailing Address - Country:US
Mailing Address - Phone:248-506-2520
Mailing Address - Fax:
Practice Address - Street 1:9444 LAPEER RD UNIT 6
Practice Address - Street 2:
Practice Address - City:DAVISON
Practice Address - State:MI
Practice Address - Zip Code:48423-1755
Practice Address - Country:US
Practice Address - Phone:914-294-4050
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-14
Last Update Date:2024-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL56008106225XP0200X
MI5201009332225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
No225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics