Provider Demographics
NPI:1831861061
Name:CRISOSTOMO, MARVIN (OTRL)
Entity type:Individual
Prefix:
First Name:MARVIN
Middle Name:
Last Name:CRISOSTOMO
Suffix:
Gender:M
Credentials:OTRL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4312 CHERRY BLOSSOM DR
Mailing Address - Street 2:
Mailing Address - City:YPSILANTI
Mailing Address - State:MI
Mailing Address - Zip Code:48197-4002
Mailing Address - Country:US
Mailing Address - Phone:734-353-8516
Mailing Address - Fax:
Practice Address - Street 1:200 SAND CREEK HWY
Practice Address - Street 2:
Practice Address - City:ADRIAN
Practice Address - State:MI
Practice Address - Zip Code:49221-1255
Practice Address - Country:US
Practice Address - Phone:517-265-8355
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-05
Last Update Date:2021-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5201011345225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist