Provider Demographics
NPI:1588060495
Name:THOMAS, KRISTEN LEE (OTRL)
Entity type:Individual
Prefix:
First Name:KRISTEN
Middle Name:LEE
Last Name:THOMAS
Suffix:
Gender:F
Credentials:OTRL
Other - Prefix:
Other - First Name:KRISTEN
Other - Middle Name:LEE
Other - Last Name:TERBRACK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:705 OLIVIA DR
Mailing Address - Street 2:
Mailing Address - City:DAVISON
Mailing Address - State:MI
Mailing Address - Zip Code:48423-1248
Mailing Address - Country:US
Mailing Address - Phone:810-625-1485
Mailing Address - Fax:
Practice Address - Street 1:521 W OHMER RD
Practice Address - Street 2:
Practice Address - City:MAYVILLE
Practice Address - State:MI
Practice Address - Zip Code:48744-8612
Practice Address - Country:US
Practice Address - Phone:989-843-6185
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-11-05
Last Update Date:2014-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5201008640225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist