Provider Demographics
NPI:1851862353
Name:DEXTER, DANIEL JAY (OTR/L, CLT, CKTP)
Entity Type:Individual
Prefix:
First Name:DANIEL
Middle Name:JAY
Last Name:DEXTER
Suffix:
Gender:M
Credentials:OTR/L, CLT, CKTP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3512 DOUGLAS AVE
Mailing Address - Street 2:
Mailing Address - City:KALAMAZOO
Mailing Address - State:MI
Mailing Address - Zip Code:49004-3605
Mailing Address - Country:US
Mailing Address - Phone:269-370-3975
Mailing Address - Fax:
Practice Address - Street 1:6120 STADIUM DR
Practice Address - Street 2:
Practice Address - City:KALAMAZOO
Practice Address - State:MI
Practice Address - Zip Code:49009-3022
Practice Address - Country:US
Practice Address - Phone:269-372-8555
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-12-09
Last Update Date:2018-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5201000436225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist