Provider Demographics
NPI:1578909271
Name:CHILDERS, ANDREA MARIE-GIMBOSA
Entity type:Individual
Prefix:MRS
First Name:ANDREA
Middle Name:MARIE-GIMBOSA
Last Name:CHILDERS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:ANDREA
Other - Middle Name:MARIE-GIMBOSA
Other - Last Name:MAITLAND
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MOT, OTRL,
Mailing Address - Street 1:1604 WITHERBEE DR
Mailing Address - Street 2:
Mailing Address - City:TROY
Mailing Address - State:MI
Mailing Address - Zip Code:48084-2684
Mailing Address - Country:US
Mailing Address - Phone:586-491-4430
Mailing Address - Fax:
Practice Address - Street 1:600 STEPHENSON HWY
Practice Address - Street 2:
Practice Address - City:TROY
Practice Address - State:MI
Practice Address - Zip Code:48083-1110
Practice Address - Country:US
Practice Address - Phone:248-616-0950
Practice Address - Fax:734-893-3154
Is Sole Proprietor?:No
Enumeration Date:2013-05-21
Last Update Date:2013-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5201007137225X00000X
225XN1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
No225XN1300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistNeurorehabilitation