Provider Demographics
NPI:1225503501
Name:KUPERUS, AUDRA LOU (COTAL)
Entity Type:Individual
Prefix:
First Name:AUDRA
Middle Name:LOU
Last Name:KUPERUS
Suffix:
Gender:F
Credentials:COTAL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6351 N BROADWAY RD
Mailing Address - Street 2:
Mailing Address - City:FREEPORT
Mailing Address - State:MI
Mailing Address - Zip Code:49325-9712
Mailing Address - Country:US
Mailing Address - Phone:616-212-9216
Mailing Address - Fax:
Practice Address - Street 1:3600 FULTON ST E
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49546-1322
Practice Address - Country:US
Practice Address - Phone:616-949-4971
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-12
Last Update Date:2020-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5202008414224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant