Provider Demographics
NPI:1851891394
Name:DARDAS, CARLENE GRACE (COTAL)
Entity Type:Individual
Prefix:MS
First Name:CARLENE
Middle Name:GRACE
Last Name:DARDAS
Suffix:
Gender:F
Credentials:COTAL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1680 N JONES RD
Mailing Address - Street 2:
Mailing Address - City:ESSEXVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:48732-1586
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2463 S M 30
Practice Address - Street 2:
Practice Address - City:WEST BRANCH
Practice Address - State:MI
Practice Address - Zip Code:48661-9312
Practice Address - Country:US
Practice Address - Phone:989-345-3660
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-20
Last Update Date:2018-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5202008011224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant