Individual
KIM ANN CORNELISSE
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Credential
COTA/L
Contact information
Practice address
3400 WILSON AVE SW, GRANDVILLE, MI 49418-1854
(616) 534-5487
Mailing address
3400 WILSON AVE SW, GRANDVILLE, MI 49418-1854
Taxonomy
Speciality
Code
Description
License number
State
224Z00000X
Occupational Therapy Assistant
Primary
5202004084
MI
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
5202004084
—
MI
Enumeration date
07/25/2018
Last updated
07/25/2018
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