Healthcare Provider Details

I. General information

NPI: 1184059826
Provider Name (Legal Business Name): LISA L SEDGLEY PTA-L
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/12/2013
Last Update Date: 01/28/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

25 CONRAN DR
COOPERSVILLE MI
49404-1366
US

IV. Provider business mailing address

17615 W MOORE PO BOX 518
GRANT MI
49327-9408
US

V. Phone/Fax

Practice location:
  • Phone: 616-997-6172
  • Fax: 616-965-2475
Mailing address:
  • Phone: 231-834-0208
  • Fax: 616-965-2475

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number5502002946
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: