Provider Demographics
NPI:1255835815
Name:HILL, KATHLEEN SUE (OTRL)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:SUE
Last Name:HILL
Suffix:
Gender:F
Credentials:OTRL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:565 N ADVANCE RD
Mailing Address - Street 2:
Mailing Address - City:EAST JORDAN
Mailing Address - State:MI
Mailing Address - Zip Code:49727-8615
Mailing Address - Country:US
Mailing Address - Phone:586-668-0096
Mailing Address - Fax:
Practice Address - Street 1:1728 S PENINSULA RD
Practice Address - Street 2:
Practice Address - City:EAST JORDAN
Practice Address - State:MI
Practice Address - Zip Code:49727-9410
Practice Address - Country:US
Practice Address - Phone:231-535-2286
Practice Address - Fax:231-536-2476
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-20
Last Update Date:2018-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5201000298225XP0019X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0019XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPhysical Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5201000298OtherOTR MICHIGAN STATE LICENSE