Healthcare Provider Details

I. General information

NPI: 1962965426
Provider Name (Legal Business Name): SUSAN ELIZABETH PORTFLEET
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/11/2019
Last Update Date: 06/19/2024
Certification Date: 06/19/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3650 VAN BUREN ST
HUDSONVILLE MI
49426-1036
US

IV. Provider business mailing address

3650 VAN BUREN ST
HUDSONVILLE MI
49426-1036
US

V. Phone/Fax

Practice location:
  • Phone: 616-669-1520
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number5501002781
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: