Healthcare Provider Details

I. General information

NPI: 1881208809
Provider Name (Legal Business Name): MORGAN PAIGE BALLMANN PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MORGAN PAIGE LENNOX

II. Dates (important events)

Enumeration Date: 09/08/2020
Last Update Date: 09/08/2020
Certification Date: 09/08/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4150 KALAMAZOO AVE. SE
GRAND RAPIDS MI
49508
US

IV. Provider business mailing address

4150 KALAMAZOO AVE. SE
GRAND RAPIDS MI
49508
US

V. Phone/Fax

Practice location:
  • Phone: 616-913-2006
  • Fax: 616-913-2005
Mailing address:
  • Phone: 616-913-2006
  • Fax: 616-913-2005

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number5502004996
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: