Provider Demographics
NPI:1316078496
Name:KIEFER, ELLEN JEAN (OTR)
Entity type:Individual
Prefix:
First Name:ELLEN
Middle Name:JEAN
Last Name:KIEFER
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:ELLEN
Other - Middle Name:JEAN
Other - Last Name:SULLIVAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OTR
Mailing Address - Street 1:43417 SCHOENHERR RD
Mailing Address - Street 2:
Mailing Address - City:STERLING HEIGHTS
Mailing Address - State:MI
Mailing Address - Zip Code:48313-1961
Mailing Address - Country:US
Mailing Address - Phone:586-532-0803
Mailing Address - Fax:586-532-0883
Practice Address - Street 1:43940 WOODWARD AVE
Practice Address - Street 2:SUITE 100B
Practice Address - City:BLOOMFIELD HILLS
Practice Address - State:MI
Practice Address - Zip Code:48302-5024
Practice Address - Country:US
Practice Address - Phone:586-532-0803
Practice Address - Fax:586-532-0883
Is Sole Proprietor?:No
Enumeration Date:2007-03-08
Last Update Date:2017-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5201006451225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIP26000008Medicare PIN