Provider Demographics
NPI:1558547570
Name:THAMMAN, SANJEEV (MHS,OTR)
Entity Type:Individual
Prefix:
First Name:SANJEEV
Middle Name:
Last Name:THAMMAN
Suffix:
Gender:M
Credentials:MHS,OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1994 TALL PINES DR SE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49546-7922
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1994 TALL PINES DR SE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49546-7922
Practice Address - Country:US
Practice Address - Phone:616-856-0102
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-21
Last Update Date:2014-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5201002120225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5201002120OtherSTATE OF MICHIGAN