Provider Demographics
NPI:1598478661
Name:MILLER, KRISTIN (COTA)
Entity Type:Individual
Prefix:
First Name:KRISTIN
Middle Name:
Last Name:MILLER
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:KRISTIN
Other - Middle Name:
Other - Last Name:SIMON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:106 PARK ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:MI
Mailing Address - Zip Code:48875-1318
Mailing Address - Country:US
Mailing Address - Phone:989-640-9427
Mailing Address - Fax:
Practice Address - Street 1:4775 VILLAGE DR
Practice Address - Street 2:
Practice Address - City:GRAND LEDGE
Practice Address - State:MI
Practice Address - Zip Code:48837-8107
Practice Address - Country:US
Practice Address - Phone:989-640-9427
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-03
Last Update Date:2023-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5202008494224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant