Provider Demographics
NPI:1487143533
Name:PENKALA, SAMUEL JOHN (OTRL)
Entity type:Individual
Prefix:
First Name:SAMUEL
Middle Name:JOHN
Last Name:PENKALA
Suffix:
Gender:M
Credentials:OTRL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:304 W WACKERLY ST STE 500
Mailing Address - Street 2:
Mailing Address - City:MIDLAND
Mailing Address - State:MI
Mailing Address - Zip Code:48640-7264
Mailing Address - Country:US
Mailing Address - Phone:989-832-4220
Mailing Address - Fax:
Practice Address - Street 1:304 W WACKERLY ST STE 500
Practice Address - Street 2:
Practice Address - City:MIDLAND
Practice Address - State:MI
Practice Address - Zip Code:48640-7264
Practice Address - Country:US
Practice Address - Phone:989-832-4220
Practice Address - Fax:989-832-4207
Is Sole Proprietor?:No
Enumeration Date:2018-05-04
Last Update Date:2018-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5201009388225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist