1295193662 NPI number — MRS. SHERRY PHONE TIP O'BANION COTA/L

Table of content: MRS. SHERRY PHONE TIP O'BANION COTA/L (NPI 1295193662)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1295193662 NPI number — MRS. SHERRY PHONE TIP O'BANION COTA/L

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
O'BANION
Provider First Name:
SHERRY
Provider Middle Name:
PHONE TIP
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
COTA/L
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
THENGKHAM
Provider Other First Name:
SHERRY
Provider Other Middle Name:
PHONE TIP
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
COTA/L
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1295193662
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/01/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
11031 E 12 MILE RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WARREN
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48093-2634
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
586-707-1183
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
320 CHURCH ST.
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MT CLEMENS
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48043
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
248-689-0468
Provider Business Practice Location Address Fax Number:
248-689-1068
Provider Enumeration Date:
02/01/2016

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 224Z00000X , with the licence number:  213305 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 224Z00000X , with the licence number: 5202007792 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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