Healthcare Provider Details

I. General information

NPI: 1043465149
Provider Name (Legal Business Name): CIBELE MAZILIAUSKAS GRANITO PT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/18/2008
Last Update Date: 03/23/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1080 E STERNBERG RD
MUSKEGON MI
49444-8796
US

IV. Provider business mailing address

1080 E STERNBERG RD
MUSKEGON MI
49444-8796
US

V. Phone/Fax

Practice location:
  • Phone: 231-799-2200
  • Fax: 231-799-2201
Mailing address:
  • Phone: 231-799-2200
  • Fax: 231-799-2201

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2251N0400X
TaxonomyNeurology Physical Therapist
License Number5501013616
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code2251P0200X
TaxonomyPediatric Physical Therapist
License Number5501013616
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: