Healthcare Provider Details

I. General information

NPI: 1124111422
Provider Name (Legal Business Name): AMY RAY PHYSICAL THERAPIST
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: AMY HODGIN PHYSICAL THERAPIST

II. Dates (important events)

Enumeration Date: 10/02/2006
Last Update Date: 04/07/2023
Certification Date: 04/07/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1272 FERN AVE
HARBOR SPRINGS MI
49740-9673
US

IV. Provider business mailing address

1272 FERN AVE
HARBOR SPRINGS MI
49740-9673
US

V. Phone/Fax

Practice location:
  • Phone: 317-450-1589
  • Fax:
Mailing address:
  • Phone: 317-450-1589
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2081S0010X
TaxonomySports Medicine (Physical Medicine & Rehabilitation) Physician
License Number05007319A
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number05007319A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: