Provider Demographics
NPI:1477028967
Name:SANDEN, LORI ELLEN (COTA)
Entity Type:Individual
Prefix:
First Name:LORI
Middle Name:ELLEN
Last Name:SANDEN
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:157 APPLEWOOD CT
Mailing Address - Street 2:
Mailing Address - City:DAVISON
Mailing Address - State:MI
Mailing Address - Zip Code:48423-9137
Mailing Address - Country:US
Mailing Address - Phone:269-788-4307
Mailing Address - Fax:
Practice Address - Street 1:13137 N CLIO RD
Practice Address - Street 2:
Practice Address - City:CLIO
Practice Address - State:MI
Practice Address - Zip Code:48420-1028
Practice Address - Country:US
Practice Address - Phone:810-686-2600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-10
Last Update Date:2018-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5202002270224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5202002270OtherCERTIFIED OCCUPATIONAL THERAPY ASSISTANT