Provider Demographics
NPI:1720828700
Name:CROOKS-SIMPKIN, KELLEN JAMES (COTA)
Entity type:Individual
Prefix:
First Name:KELLEN
Middle Name:JAMES
Last Name:CROOKS-SIMPKIN
Suffix:
Gender:M
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:945 WOODWARD AVE
Mailing Address - Street 2:
Mailing Address - City:KINGSFORD
Mailing Address - State:MI
Mailing Address - Zip Code:49802-4400
Mailing Address - Country:US
Mailing Address - Phone:616-885-0888
Mailing Address - Fax:
Practice Address - Street 1:945 WOODWARD AVE APT 10
Practice Address - Street 2:
Practice Address - City:KINGSFORD
Practice Address - State:MI
Practice Address - Zip Code:49802-4458
Practice Address - Country:US
Practice Address - Phone:616-885-0888
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-05-28
Last Update Date:2024-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5202008722224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant