MEDICARE: COLLEEN JOHAN ZDEB LPTA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225200000X	Physical Therapy Assistant	5502000054	MI

General Provider Information

NPI Number	:	1548504442
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	COLLEEN JOHAN ZDEB LPTA

Provider Business Mailing Address
First Line	:	5116 WAKEFIELD RD
Second Line	:
City	:	GRAND BLANC
State	:	MI
Zip	:	48439-9189
Country	:	US
Telephone Number	:	810-516-1902
Fax Number	:

Provider Business Practice Location Address
First Line	:	5116 WAKEFIELD RD
Second Line	:
City	:	GRAND BLANC
State	:	MI
Zip	:	48439
Country	:	US
Telephone Number	:	810-516-1902
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/15/2012
Last Update Date	:	11/15/2012

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