Healthcare Provider Details

I. General information

NPI: 1952896672
Provider Name (Legal Business Name): CHEYENNE TAYLER BOLENBAUGH CTRS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/25/2018
Last Update Date: 06/25/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7537 LEE RD APT B
JACKSON MI
49201-8152
US

IV. Provider business mailing address

7537 LEE RD APT B
JACKSON MI
49201-8152
US

V. Phone/Fax

Practice location:
  • Phone: 517-554-1491
  • Fax:
Mailing address:
  • Phone: 517-554-1491
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225800000X
TaxonomyRecreation Therapist
License Number80603
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: