Provider Demographics
NPI:1750055646
Name:PITKIN, CORALEA CARROLL (MSOT, OTRL)
Entity Type:Individual
Prefix:
First Name:CORALEA
Middle Name:CARROLL
Last Name:PITKIN
Suffix:
Gender:F
Credentials:MSOT, OTRL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:223 PRIMROSE LN
Mailing Address - Street 2:
Mailing Address - City:FLUSHING
Mailing Address - State:MI
Mailing Address - Zip Code:48433-2699
Mailing Address - Country:US
Mailing Address - Phone:810-265-3953
Mailing Address - Fax:
Practice Address - Street 1:16260 PARK LAKE RD
Practice Address - Street 2:
Practice Address - City:EAST LANSING
Practice Address - State:MI
Practice Address - Zip Code:48823-9480
Practice Address - Country:US
Practice Address - Phone:517-339-2322
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-04
Last Update Date:2022-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5201011235225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist