Provider Demographics
NPI:1063169548
Name:WINCHESTER, ELISE (OTRL)
Entity type:Individual
Prefix:
First Name:ELISE
Middle Name:
Last Name:WINCHESTER
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 1:25900 GREENFIELD RD STE 100
Mailing Address - Street 2:
Mailing Address - City:OAK PARK
Mailing Address - State:MI
Mailing Address - Zip Code:48237-1297
Mailing Address - Country:US
Mailing Address - Phone:248-788-4300
Mailing Address - Fax:
Practice Address - Street 1:25900 GREENFIELD RD STE 100
Practice Address - Street 2:
Practice Address - City:OAK PARK
Practice Address - State:MI
Practice Address - Zip Code:48237-1297
Practice Address - Country:US
Practice Address - Phone:248-788-4300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-03-04
Last Update Date:2022-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5201012851225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist