Provider Demographics
NPI:1437793601
Name:FAFULOVIC, KIERSTIN (OT)
Entity Type:Individual
Prefix:
First Name:KIERSTIN
Middle Name:
Last Name:FAFULOVIC
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:KIERSTIN
Other - Middle Name:
Other - Last Name:LEAK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OT
Mailing Address - Street 1:33900 HARPER AVE STE 104
Mailing Address - Street 2:
Mailing Address - City:CLINTON TWP
Mailing Address - State:MI
Mailing Address - Zip Code:48035-4258
Mailing Address - Country:US
Mailing Address - Phone:586-350-2644
Mailing Address - Fax:
Practice Address - Street 1:30100 TELEGRAPH RD STE 140
Practice Address - Street 2:
Practice Address - City:BINGHAM FARMS
Practice Address - State:MI
Practice Address - Zip Code:48025-4516
Practice Address - Country:US
Practice Address - Phone:248-385-0030
Practice Address - Fax:248-849-9980
Is Sole Proprietor?:No
Enumeration Date:2019-10-31
Last Update Date:2021-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
225X00000X
MI5201009369225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist