Provider Demographics
NPI:1811450364
Name:TENBROEKE, CAROLYN
Entity type:Individual
Prefix:
First Name:CAROLYN
Middle Name:
Last Name:TENBROEKE
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 1:1611 FORRESTER ST SE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49508-1466
Mailing Address - Country:US
Mailing Address - Phone:616-617-0395
Mailing Address - Fax:
Practice Address - Street 1:425 E ELM ST
Practice Address - Street 2:
Practice Address - City:WAYLAND
Practice Address - State:MI
Practice Address - Zip Code:49348-1109
Practice Address - Country:US
Practice Address - Phone:269-792-2249
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-11
Last Update Date:2019-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant