Provider Demographics
NPI:1205393691
Name:POELSTRA, NANCY ROSEANN (OTR/L)
Entity Type:Individual
Prefix:
First Name:NANCY
Middle Name:ROSEANN
Last Name:POELSTRA
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 1:5556 LAWRENCE CT
Mailing Address - Street 2:
Mailing Address - City:PINCKNEY
Mailing Address - State:MI
Mailing Address - Zip Code:48169-9257
Mailing Address - Country:US
Mailing Address - Phone:586-899-6574
Mailing Address - Fax:
Practice Address - Street 1:4000 N MICHIGAN RD
Practice Address - Street 2:
Practice Address - City:DIMONDALE
Practice Address - State:MI
Practice Address - Zip Code:48821-9744
Practice Address - Country:US
Practice Address - Phone:517-646-6258
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-21
Last Update Date:2019-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD425645225XP0019X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0019XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPhysical Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD425645OtherAMERICAN OCCUPATIONA THERAPY ASSOCIATION