Provider Demographics
NPI:1275169500
Name:GOERGE, SYDNEY BROOKE (OTRL)
Entity Type:Individual
Prefix:MS
First Name:SYDNEY
Middle Name:BROOKE
Last Name:GOERGE
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 1:11020 W WALKER RD
Mailing Address - Street 2:
Mailing Address - City:FOWLER
Mailing Address - State:MI
Mailing Address - Zip Code:48835-8715
Mailing Address - Country:US
Mailing Address - Phone:989-400-2775
Mailing Address - Fax:
Practice Address - Street 1:4285 DEVELOPMENT DR
Practice Address - Street 2:
Practice Address - City:LANSING
Practice Address - State:MI
Practice Address - Zip Code:48911-4213
Practice Address - Country:US
Practice Address - Phone:042-151-7706
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-18
Last Update Date:2021-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5201010880225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist