Provider Demographics
NPI:1063783173
Name:EICHHORST, AGNES MONICA (OT)
Entity type:Individual
Prefix:
First Name:AGNES
Middle Name:MONICA
Last Name:EICHHORST
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 822
Mailing Address - Street 2:
Mailing Address - City:WHITE CLOUD
Mailing Address - State:MI
Mailing Address - Zip Code:49349-0822
Mailing Address - Country:US
Mailing Address - Phone:231-689-5800
Mailing Address - Fax:231-689-5802
Practice Address - Street 1:220 S. CHARLES
Practice Address - Street 2:
Practice Address - City:WHITE CLOUD
Practice Address - State:MI
Practice Address - Zip Code:49349-8794
Practice Address - Country:US
Practice Address - Phone:231-689-5800
Practice Address - Fax:231-689-5802
Is Sole Proprietor?:No
Enumeration Date:2012-01-20
Last Update Date:2012-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5201000586225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist