Healthcare Provider Details

I. General information

NPI: 1316482839
Provider Name (Legal Business Name): BETHANY SUZANNE CUATT ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/20/2016
Last Update Date: 12/20/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

206 PAGE AVE
JACKSON MI
49201-2418
US

IV. Provider business mailing address

302 CHURCH ST
PARMA MI
49269
US

V. Phone/Fax

Practice location:
  • Phone: 517-740-3496
  • Fax: 517-841-8282
Mailing address:
  • Phone: 517-740-3496
  • Fax: 517-841-8282

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number2601001161
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: