Provider Demographics
NPI:1891933503
Name:GREAT LAKES NEURO-REHABILITATION SERVICES
Entity Type:Organization
Organization Name:GREAT LAKES NEURO-REHABILITATION SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:GAY
Authorized Official - Middle Name:JANEL
Authorized Official - Last Name:LANDENBERG
Authorized Official - Suffix:
Authorized Official - Credentials:MOT, OTR
Authorized Official - Phone:810-625-0785
Mailing Address - Street 1:2237 WESTERN MEADOWS DR
Mailing Address - Street 2:
Mailing Address - City:FLUSHING
Mailing Address - State:MI
Mailing Address - Zip Code:48433-9412
Mailing Address - Country:US
Mailing Address - Phone:810-625-0785
Mailing Address - Fax:
Practice Address - Street 1:2237 WESTERN MEADOWS DR
Practice Address - Street 2:
Practice Address - City:FLUSHING
Practice Address - State:MI
Practice Address - Zip Code:48433-9412
Practice Address - Country:US
Practice Address - Phone:810-625-0785
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-02-03
Last Update Date:2009-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5201004988225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty