Provider Demographics
NPI:1396228003
Name:BAILEY, MATTHEW MICHAEL (COTA/L)
Entity Type:Individual
Prefix:MR
First Name:MATTHEW
Middle Name:MICHAEL
Last Name:BAILEY
Suffix:
Gender:M
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5690 FOREST VIEW ST
Mailing Address - Street 2:
Mailing Address - City:ALLENDALE
Mailing Address - State:MI
Mailing Address - Zip Code:49401-9325
Mailing Address - Country:US
Mailing Address - Phone:616-540-4738
Mailing Address - Fax:
Practice Address - Street 1:900 S BEACON BLVD
Practice Address - Street 2:
Practice Address - City:GRAND HAVEN
Practice Address - State:MI
Practice Address - Zip Code:49417-2146
Practice Address - Country:US
Practice Address - Phone:616-846-1850
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-09
Last Update Date:2018-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5202008415224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant