Provider Demographics
NPI:1134618036
Name:REISS, CAROL (MS OTRL)
Entity type:Individual
Prefix:
First Name:CAROL
Middle Name:
Last Name:REISS
Suffix:
Gender:F
Credentials:MS OTRL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3685 ANDOVER LN
Mailing Address - Street 2:
Mailing Address - City:HUDSONVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:49426-7872
Mailing Address - Country:US
Mailing Address - Phone:616-826-3733
Mailing Address - Fax:
Practice Address - Street 1:625 KENMOOR AVE SE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49546-2395
Practice Address - Country:US
Practice Address - Phone:616-942-5744
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-07
Last Update Date:2018-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI1306876438225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist