Provider Demographics
NPI:1578051942
Name:VON HENNER, ELISE DANIELLE (COTA/L)
Entity Type:Individual
Prefix:MRS
First Name:ELISE
Middle Name:DANIELLE
Last Name:VON HENNER
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:MISS
Other - First Name:ELISE
Other - Middle Name:DANIELLE
Other - Last Name:PEAK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:COTA/L
Mailing Address - Street 1:1652 PARKVIEW DR
Mailing Address - Street 2:
Mailing Address - City:NILES
Mailing Address - State:MI
Mailing Address - Zip Code:49120-4547
Mailing Address - Country:US
Mailing Address - Phone:269-240-3842
Mailing Address - Fax:
Practice Address - Street 1:1333 WELLS ST
Practice Address - Street 2:
Practice Address - City:NILES
Practice Address - State:MI
Practice Address - Zip Code:49120-1543
Practice Address - Country:US
Practice Address - Phone:269-240-3842
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-01
Last Update Date:2018-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5202008195224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy AssistantGroup - Single Specialty