Provider Demographics
NPI:1417064148
Name:SELLENRAAD, MEGAN AUBREY (OTR/L)
Entity Type:Individual
Prefix:
First Name:MEGAN
Middle Name:AUBREY
Last Name:SELLENRAAD
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:MRS
Other - First Name:MEGAN
Other - Middle Name:AUBREY
Other - Last Name:SELLENRAAD-HAMELIN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:OTR/L
Mailing Address - Street 1:8080 N SWEDE RD
Mailing Address - Street 2:
Mailing Address - City:NORTHPORT
Mailing Address - State:MI
Mailing Address - Zip Code:49670-9401
Mailing Address - Country:US
Mailing Address - Phone:231-386-7298
Mailing Address - Fax:231-929-2853
Practice Address - Street 1:808 S GARFIELD AVE
Practice Address - Street 2:SUITE A
Practice Address - City:TRAVERSE CITY
Practice Address - State:MI
Practice Address - Zip Code:49686-3464
Practice Address - Country:US
Practice Address - Phone:231-929-2354
Practice Address - Fax:231-929-2853
Is Sole Proprietor?:No
Enumeration Date:2006-08-25
Last Update Date:2011-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL056-007436225X00000X
MI5201007598225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILA2741KD1Medicaid
ILK22557Medicare ID - Type UnspecifiedOCCUPATIONAL THERAPY