Provider Demographics
NPI:1295138014
Name:KISSELL, SONDRA LYNN
Entity type:Individual
Prefix:
First Name:SONDRA
Middle Name:LYNN
Last Name:KISSELL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20668 HIBMA RD
Mailing Address - Street 2:
Mailing Address - City:TUSTIN
Mailing Address - State:MI
Mailing Address - Zip Code:49688-8241
Mailing Address - Country:US
Mailing Address - Phone:814-248-9144
Mailing Address - Fax:
Practice Address - Street 1:600 SE 4TH ST
Practice Address - Street 2:
Practice Address - City:CLARE
Practice Address - State:MI
Practice Address - Zip Code:48617-9201
Practice Address - Country:US
Practice Address - Phone:989-386-7723
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-10-07
Last Update Date:2014-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI3658528224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant