Healthcare Provider Details

I. General information

NPI: 1457575862
Provider Name (Legal Business Name): BRENDA M ENGELS PT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/13/2007
Last Update Date: 01/04/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4069 LAKE DRV SE SUITE 114
GRAND RAPIDS MI
49546-2444
US

IV. Provider business mailing address

4085 BURTON ST SE SUITE 200
GRAND RAPIDS MI
49546-2444
US

V. Phone/Fax

Practice location:
  • Phone: 616-726-8365
  • Fax:
Mailing address:
  • Phone: 616-284-8805
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number5501006560
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: