Healthcare Provider Details

I. General information

NPI: 1568089712
Provider Name (Legal Business Name): TRACY M KLEIN LMT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/02/2020
Last Update Date: 07/02/2020
Certification Date: 07/02/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3501 LAKE EASTBROOK BLVD SE STE 345
GRAND RAPIDS MI
49546-5964
US

IV. Provider business mailing address

953 FRANKLIN ST SE
GRAND RAPIDS MI
49507-1324
US

V. Phone/Fax

Practice location:
  • Phone: 602-301-1378
  • Fax:
Mailing address:
  • Phone: 602-301-1378
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number7501001334
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: