Healthcare Provider Details

I. General information

NPI: 1003778721
Provider Name (Legal Business Name): JUSTIN THOMAS FELICZAK
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/01/2025
Last Update Date: 12/01/2025
Certification Date: 12/01/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 JEFFREY ST
CEDAR SPRINGS MI
49319-9572
US

IV. Provider business mailing address

3205 SOFT WATER LAKE DR NE APT 9-204
GRAND RAPIDS MI
49525-2748
US

V. Phone/Fax

Practice location:
  • Phone: 616-696-0170
  • Fax:
Mailing address:
  • Phone: 231-510-5079
  • Fax: 231-510-5079

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: