Provider Demographics
NPI:1518438316
Name:ROSELLE, SANDRA LORRAINE
Entity Type:Individual
Prefix:
First Name:SANDRA
Middle Name:LORRAINE
Last Name:ROSELLE
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 1:3350 CEMETERY RD
Mailing Address - Street 2:
Mailing Address - City:FOWLERVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:48836-9537
Mailing Address - Country:US
Mailing Address - Phone:517-294-2542
Mailing Address - Fax:
Practice Address - Street 1:34505 W 12 MILE RD
Practice Address - Street 2:
Practice Address - City:FARMINGTON HILLS
Practice Address - State:MI
Practice Address - Zip Code:48331-3258
Practice Address - Country:US
Practice Address - Phone:734-343-7500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-12-06
Last Update Date:2018-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5201001277225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1508823774Medicaid