Healthcare Provider Details

I. General information

NPI: 1275272247
Provider Name (Legal Business Name): MICHAELA MAGRY PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/31/2022
Last Update Date: 05/31/2022
Certification Date: 05/05/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

148 S MAIN ST
LESLIE MI
49251-2561
US

IV. Provider business mailing address

4480 WILLOUGHBY RD
HOLT MI
48842-9413
US

V. Phone/Fax

Practice location:
  • Phone: 517-589-9050
  • Fax: 517-589-9059
Mailing address:
  • Phone: 248-220-3510
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number5502005375
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: