Healthcare Provider Details

I. General information

NPI: 1689042608
Provider Name (Legal Business Name): MARY BJORN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/08/2015
Last Update Date: 09/08/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1013 BUMBLETOWN RD
ALLOUEZ MI
49805-6930
US

IV. Provider business mailing address

1013 BUMBLETOWN RD
ALLOUEZ MI
49805-6930
US

V. Phone/Fax

Practice location:
  • Phone: 906-370-2019
  • Fax:
Mailing address:
  • Phone: 906-370-2019
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number5502003396
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: