Provider Demographics
NPI:1013485184
Name:NORTHROP, CLINT M (COTA)
Entity type:Individual
Prefix:
First Name:CLINT
Middle Name:M
Last Name:NORTHROP
Suffix:
Gender:M
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5148 WOODSTOCK DR
Mailing Address - Street 2:
Mailing Address - City:SWARTZ CREEK
Mailing Address - State:MI
Mailing Address - Zip Code:48473-8543
Mailing Address - Country:US
Mailing Address - Phone:810-837-1602
Mailing Address - Fax:
Practice Address - Street 1:3500 COOLIDGE RD
Practice Address - Street 2:
Practice Address - City:EAST LANSING
Practice Address - State:MI
Practice Address - Zip Code:48823-6376
Practice Address - Country:US
Practice Address - Phone:517-203-4042
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-07
Last Update Date:2018-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5202008386224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant