Healthcare Provider Details

I. General information

NPI: 1891269429
Provider Name (Legal Business Name): TONYA RENE PRIESE PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/16/2019
Last Update Date: 01/16/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 LAKESIDE DR NE
GRAND RAPIDS MI
49503-3811
US

IV. Provider business mailing address

2526 RAY AVE
NEW ERA MI
49446-9641
US

V. Phone/Fax

Practice location:
  • Phone: 616-588-1645
  • Fax:
Mailing address:
  • Phone: 231-301-9518
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number5502004698
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: