Provider Demographics
NPI:1548764434
Name:KOVACIK, THERESA LYNN (OTRL)
Entity Type:Individual
Prefix:
First Name:THERESA
Middle Name:LYNN
Last Name:KOVACIK
Suffix:
Gender:F
Credentials:OTRL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:21883 WAYCROSS DR
Mailing Address - Street 2:
Mailing Address - City:MACOMB
Mailing Address - State:MI
Mailing Address - Zip Code:48044-2325
Mailing Address - Country:US
Mailing Address - Phone:586-216-8341
Mailing Address - Fax:248-828-4226
Practice Address - Street 1:5877 LIVERNOIS RD STE 101
Practice Address - Street 2:
Practice Address - City:TROY
Practice Address - State:MI
Practice Address - Zip Code:48098-3100
Practice Address - Country:US
Practice Address - Phone:248-828-3800
Practice Address - Fax:248-828-4226
Is Sole Proprietor?:No
Enumeration Date:2018-03-23
Last Update Date:2020-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5201007476225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist