Provider Demographics
NPI:1801464615
Name:KENNY, ERICKA (OTRL)
Entity type:Individual
Prefix:
First Name:ERICKA
Middle Name:
Last Name:KENNY
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 1:15010 FROST RD
Mailing Address - Street 2:
Mailing Address - City:HEMLOCK
Mailing Address - State:MI
Mailing Address - Zip Code:48626-9664
Mailing Address - Country:US
Mailing Address - Phone:989-573-2988
Mailing Address - Fax:
Practice Address - Street 1:1222 NORTH DR
Practice Address - Street 2:
Practice Address - City:MT PLEASANT
Practice Address - State:MI
Practice Address - Zip Code:48858-3200
Practice Address - Country:US
Practice Address - Phone:989-772-2957
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-16
Last Update Date:2021-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5201011231225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
449661OtherNATIONAL BOARD FOR CERTIFICATION IN OCCUPATIONAL THERAPY
205501915792OtherAMERICAN HEART ASSOCIATION
MI5201011231OtherMICHIGAN BOARD OF OCCUPATIONAL THERAPY