Healthcare Provider Details

I. General information

NPI: 1306086335
Provider Name (Legal Business Name): MARISSA DANIELLE WHEELER DPT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/04/2009
Last Update Date: 04/23/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5570 WILSON AVE SW SUITE A.
GRANDVILLE MI
49418-1496
US

IV. Provider business mailing address

2120 43RD ST SE SUITE 100
GRAND RAPIDS MI
49508-3772
US

V. Phone/Fax

Practice location:
  • Phone: 616-855-1495
  • Fax: 616-855-1496
Mailing address:
  • Phone: 616-281-1144
  • Fax: 616-281-1221

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number5501014132
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: