Provider Demographics
NPI:1306567722
Name:GAGO, ANDRAYA LYNN (OTRL)
Entity type:Individual
Prefix:
First Name:ANDRAYA
Middle Name:LYNN
Last Name:GAGO
Suffix:
Gender:F
Credentials:OTRL
Other - Prefix:
Other - First Name:ANDRAYA
Other - Middle Name:LYNN
Other - Last Name:MUSALLAM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:28425 HENDRIE ST
Mailing Address - Street 2:
Mailing Address - City:CHESTERFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48047-5217
Mailing Address - Country:US
Mailing Address - Phone:586-549-1162
Mailing Address - Fax:
Practice Address - Street 1:41155 POND VIEW DR
Practice Address - Street 2:
Practice Address - City:STERLING HEIGHTS
Practice Address - State:MI
Practice Address - Zip Code:48314-3891
Practice Address - Country:US
Practice Address - Phone:586-217-3908
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-09-05
Last Update Date:2022-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5201013071225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist