Healthcare Provider Details

I. General information

NPI: 1881257822
Provider Name (Legal Business Name): KAMY BETH ZWAK
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/16/2019
Last Update Date: 04/16/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1080 N 35TH ST
GALESBURG MI
49053-9727
US

IV. Provider business mailing address

6567 EASTERN AVE SE
GRAND RAPIDS MI
49508-7045
US

V. Phone/Fax

Practice location:
  • Phone: 269-665-7043
  • Fax:
Mailing address:
  • Phone: 616-901-6706
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number5202007671
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: