Provider Demographics
NPI:1548767049
Name:DISANTO, DOREEN MARIE I (OTRL)
Entity Type:Individual
Prefix:
First Name:DOREEN
Middle Name:MARIE
Last Name:DISANTO
Suffix:I
Gender:F
Credentials:OTRL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15475 ORCHARD RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:CLINTON TOWNSHIP
Mailing Address - State:MI
Mailing Address - Zip Code:48038-1692
Mailing Address - Country:US
Mailing Address - Phone:248-765-0305
Mailing Address - Fax:
Practice Address - Street 1:1410 E 14 MILE RD
Practice Address - Street 2:
Practice Address - City:MADISON HEIGHTS
Practice Address - State:MI
Practice Address - Zip Code:48071-1541
Practice Address - Country:US
Practice Address - Phone:248-819-0045
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-11
Last Update Date:2018-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5201001035225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist