Healthcare Provider Details

I. General information

NPI: 1174138655
Provider Name (Legal Business Name): EMILY GEBOLYS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/11/2020
Last Update Date: 09/11/2020
Certification Date: 09/11/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

900 S BEACON BLVD
GRAND HAVEN MI
49417-2146
US

IV. Provider business mailing address

900 S BEACON BLVD
GRAND HAVEN MI
49417-2146
US

V. Phone/Fax

Practice location:
  • Phone: 616-296-7300
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number5502000233
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: