Provider Demographics
NPI:1184265068
Name:KING, TIYANA SIDNI (OTRL)
Entity type:Individual
Prefix:
First Name:TIYANA
Middle Name:SIDNI
Last Name:KING
Suffix:
Gender:F
Credentials:OTRL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20000 VICTOR PKWY STE 100
Mailing Address - Street 2:
Mailing Address - City:LIVONIA
Mailing Address - State:MI
Mailing Address - Zip Code:48152-7027
Mailing Address - Country:US
Mailing Address - Phone:734-743-2909
Mailing Address - Fax:734-953-1743
Practice Address - Street 1:20000 VICTOR PKWY STE 100
Practice Address - Street 2:
Practice Address - City:LIVONIA
Practice Address - State:MI
Practice Address - Zip Code:48152-7027
Practice Address - Country:US
Practice Address - Phone:734-743-2909
Practice Address - Fax:734-953-1743
Is Sole Proprietor?:No
Enumeration Date:2019-10-02
Last Update Date:2019-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5201010706225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist