Provider Demographics
NPI:1184820821
Name:CORRELL, PAMELA SUE (OTR)
Entity Type:Individual
Prefix:MS
First Name:PAMELA
Middle Name:SUE
Last Name:CORRELL
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1001 MEDICAL PARK DR SE
Mailing Address - Street 2:SUITE 111
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49546-3610
Mailing Address - Country:US
Mailing Address - Phone:616-957-4014
Mailing Address - Fax:616-956-0059
Practice Address - Street 1:1001 MEDICAL PARK DR SE
Practice Address - Street 2:SUITE 111
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49546-3610
Practice Address - Country:US
Practice Address - Phone:616-957-4014
Practice Address - Fax:616-956-0059
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5201000379225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist