Provider Demographics
NPI:1932662483
Name:GRAEBER, MATTHEW JON (OTR)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:JON
Last Name:GRAEBER
Suffix:
Gender:M
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15643 KATHERINE TRL
Mailing Address - Street 2:
Mailing Address - City:MARSHALL
Mailing Address - State:MI
Mailing Address - Zip Code:49068-9475
Mailing Address - Country:US
Mailing Address - Phone:269-986-3990
Mailing Address - Fax:
Practice Address - Street 1:90 N MICHIGAN AVE
Practice Address - Street 2:
Practice Address - City:COLDWATER
Practice Address - State:MI
Practice Address - Zip Code:49036-1527
Practice Address - Country:US
Practice Address - Phone:517-279-9808
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-11
Last Update Date:2021-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5201006064225X00000X
225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5201006064OtherBOARD OF OCCUPATIONAL THERAPISTS
MI5201006064OtherDEPARTMENT OF LICENSING AND REGULATORY AFFAIRS