Healthcare Provider Details

I. General information

NPI: 1043749732
Provider Name (Legal Business Name): EMILY MARIE FASE DPT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: EMILY MARIE EMERICK

II. Dates (important events)

Enumeration Date: 06/07/2017
Last Update Date: 02/20/2023
Certification Date: 02/20/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

25 CONRAN DR
COOPERSVILLE MI
49404-1300
US

IV. Provider business mailing address

1311 MAMARONECK AVE STE 140
WHITE PLAINS NY
10605-5224
US

V. Phone/Fax

Practice location:
  • Phone: 616-997-6172
  • Fax: 616-965-2475
Mailing address:
  • Phone: 914-294-4050
  • Fax: 631-760-8306

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225400000X
TaxonomyRehabilitation Practitioner
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number5501020147
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: