Provider Demographics
NPI:1679090328
Name:MALBURG, KAITLYN GRACE (OTR/L)
Entity type:Individual
Prefix:
First Name:KAITLYN
Middle Name:GRACE
Last Name:MALBURG
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3916 CHURCH RD
Mailing Address - Street 2:
Mailing Address - City:CASCO
Mailing Address - State:MI
Mailing Address - Zip Code:48064-1805
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:9100 LAPEER RD
Practice Address - Street 2:
Practice Address - City:DAVISON
Practice Address - State:MI
Practice Address - Zip Code:48423-3620
Practice Address - Country:US
Practice Address - Phone:810-653-0100
Practice Address - Fax:810-653-0133
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-24
Last Update Date:2017-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5201009671225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty