Healthcare Provider Details

I. General information

NPI: 1902178676
Provider Name (Legal Business Name): JOSHUA HANENBURG PT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/27/2012
Last Update Date: 01/20/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5886 VENTURE PARK DR
KALAMAZOO MI
49009-1848
US

IV. Provider business mailing address

1331 LAKE DR SE STE 105
GRAND RAPIDS MI
49506-1674
US

V. Phone/Fax

Practice location:
  • Phone: 269-375-4737
  • Fax: 269-375-4747
Mailing address:
  • Phone: 616-356-5000
  • Fax: 616-356-5001

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number5501014787
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: