Healthcare Provider Details

I. General information

NPI: 1740864248
Provider Name (Legal Business Name): CARLEY MANGUS PT, DPT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/11/2021
Last Update Date: 05/11/2021
Certification Date: 05/07/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1401 CEDAR ST NE
GRAND RAPIDS MI
49503-1375
US

IV. Provider business mailing address

175 DENILEE CT NE
COMSTOCK PARK MI
49321-9614
US

V. Phone/Fax

Practice location:
  • Phone: 616-486-3900
  • Fax:
Mailing address:
  • Phone: 616-325-8182
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number5501016011
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: