Healthcare Provider Details

I. General information

NPI: 1649529918
Provider Name (Legal Business Name): NORA ANNE HEGSTROM PT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/02/2012
Last Update Date: 12/18/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2550 MEADOWBROOK RD STE 110
BENTON HARBOR MI
49022-9609
US

IV. Provider business mailing address

2550 MEADOWBROOK RD STE 110
BENTON HARBOR MI
49022-9609
US

V. Phone/Fax

Practice location:
  • Phone: 269-985-4400
  • Fax:
Mailing address:
  • Phone: 269-985-4400
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number5501016021
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: