Healthcare Provider Details

I. General information

NPI: 1790498087
Provider Name (Legal Business Name): CATHERINE MINGLEDORFF
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: BETH MINGLEDORFF

II. Dates (important events)

Enumeration Date: 01/02/2023
Last Update Date: 01/02/2023
Certification Date: 01/02/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

233 FULTON ST E STE 210E
GRAND RAPIDS MI
49503-3261
US

IV. Provider business mailing address

653 SPENCER ST NE
GRAND RAPIDS MI
49505-5207
US

V. Phone/Fax

Practice location:
  • Phone: 616-425-9550
  • Fax:
Mailing address:
  • Phone: 773-251-5960
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number7501011507
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: