Provider Demographics
NPI:1700424397
Name:GENDERNALIK, ELIZABETH (OTR/L)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:
Last Name:GENDERNALIK
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3973 S 120TH AVE
Mailing Address - Street 2:
Mailing Address - City:SHELBY
Mailing Address - State:MI
Mailing Address - Zip Code:49455-9774
Mailing Address - Country:US
Mailing Address - Phone:989-745-3971
Mailing Address - Fax:
Practice Address - Street 1:1027 HEALTHCARE DR
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:MI
Practice Address - Zip Code:48813-1056
Practice Address - Country:US
Practice Address - Phone:517-541-5001
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-12-15
Last Update Date:2019-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5201010780225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist