Healthcare Provider Details

I. General information

NPI: 1669984985
Provider Name (Legal Business Name): SUSAN ATHEY PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/26/2017
Last Update Date: 10/26/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1971 E BELTLINE AVE NE
GRAND RAPIDS MI
49525-7045
US

IV. Provider business mailing address

5563 MYERS LAKE AVE NE
BELMONT MI
49306-9644
US

V. Phone/Fax

Practice location:
  • Phone: 617-575-0216
  • Fax:
Mailing address:
  • Phone: 773-531-7481
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2081N0008X
TaxonomyNeuromuscular Medicine (Physical Medicine & Rehabilitation) Physician
License Number4466951
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: