Healthcare Provider Details

I. General information

NPI: 1285911875
Provider Name (Legal Business Name): EMILY PEARSON AT, ATC, CSCS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/09/2011
Last Update Date: 11/09/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1700 N GREENFIELD CIR NE APT 102
GRAND RAPIDS MI
49505-5673
US

IV. Provider business mailing address

1700 N GREENFIELD CIR NE APT 102
GRAND RAPIDS MI
49505-5673
US

V. Phone/Fax

Practice location:
  • Phone: 616-848-0309
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number2601000632
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: