Healthcare Provider Details

I. General information

NPI: 1972374940
Provider Name (Legal Business Name): ALEXIS BRANSHAW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/09/2024
Last Update Date: 04/16/2026
Certification Date: 04/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

235 WEALTHY ST SE
GRAND RAPIDS MI
49503-5247
US

IV. Provider business mailing address

756 INDIAN LAKES RD NW
SPARTA MI
49345-8545
US

V. Phone/Fax

Practice location:
  • Phone: 616-840-8000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number5201014313
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: