Provider Demographics
NPI:1326519927
Name:RAY, RITA
Entity Type:Individual
Prefix:
First Name:RITA
Middle Name:
Last Name:RAY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:144 ALLEN LAKE DR
Mailing Address - Street 2:
Mailing Address - City:WHITE LAKE
Mailing Address - State:MI
Mailing Address - Zip Code:48386-2402
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:34505 W 12 MILE RD STE 100
Practice Address - Street 2:
Practice Address - City:FARMINGTON HILLS
Practice Address - State:MI
Practice Address - Zip Code:48331-3287
Practice Address - Country:US
Practice Address - Phone:734-343-7518
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-12-09
Last Update Date:2018-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5201003849225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1508823774Medicaid