Provider Demographics
NPI:1447731336
Name:TEWELL, KIMBERLY ROSE (COTA)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:ROSE
Last Name:TEWELL
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:KIMBERLY
Other - Middle Name:ROSE
Other - Last Name:KIRK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:COTA
Mailing Address - Street 1:19203 PORTER DR
Mailing Address - Street 2:
Mailing Address - City:CLINTON TOWNSHIP
Mailing Address - State:MI
Mailing Address - Zip Code:48038-3087
Mailing Address - Country:US
Mailing Address - Phone:586-883-2911
Mailing Address - Fax:
Practice Address - Street 1:14900 SHORELINE DR
Practice Address - Street 2:
Practice Address - City:STERLING HEIGHTS
Practice Address - State:MI
Practice Address - Zip Code:48313-2251
Practice Address - Country:US
Practice Address - Phone:586-247-4700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-28
Last Update Date:2018-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI52027479224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant