Provider Demographics
NPI:1649878588
Name:OUTSIDE OT L.L.C.
Entity type:Organization
Organization Name:OUTSIDE OT L.L.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER AND OCCUPATIONAL THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:NICOLE
Authorized Official - Middle Name:
Authorized Official - Last Name:GORDON
Authorized Official - Suffix:
Authorized Official - Credentials:OTR/L
Authorized Official - Phone:313-438-8816
Mailing Address - Street 1:63999 INDIAN TRL
Mailing Address - Street 2:
Mailing Address - City:RAY
Mailing Address - State:MI
Mailing Address - Zip Code:48096-2516
Mailing Address - Country:US
Mailing Address - Phone:313-438-8816
Mailing Address - Fax:
Practice Address - Street 1:63999 INDIAN TRL
Practice Address - Street 2:
Practice Address - City:RAY
Practice Address - State:MI
Practice Address - Zip Code:48096-2516
Practice Address - Country:US
Practice Address - Phone:313-438-8816
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-10-13
Last Update Date:2020-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI000000000OtherOPTIONAL