Provider Demographics
NPI:1093536229
Name:SMALL, DEANNA L (PTA, COTA)
Entity type:Individual
Prefix:
First Name:DEANNA
Middle Name:L
Last Name:SMALL
Suffix:
Gender:F
Credentials:PTA, COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10650 HEETHER RD
Mailing Address - Street 2:
Mailing Address - City:BELDING
Mailing Address - State:MI
Mailing Address - Zip Code:48809-8717
Mailing Address - Country:US
Mailing Address - Phone:616-292-2362
Mailing Address - Fax:
Practice Address - Street 1:620 N 2ND ST
Practice Address - Street 2:
Practice Address - City:CARSON CITY
Practice Address - State:MI
Practice Address - Zip Code:48811-9790
Practice Address - Country:US
Practice Address - Phone:989-584-6100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-10-21
Last Update Date:2024-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5502003329225200000X
MI5202007265224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant
No225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant