Healthcare Provider Details

I. General information

NPI: 1053875633
Provider Name (Legal Business Name): STEFANIE BUMSTEAD PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/28/2019
Last Update Date: 01/28/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1712 HOLTON RD STE B
MUSKEGON MI
49445-3408
US

IV. Provider business mailing address

1712 HOLTON RD STE B
MUSKEGON MI
49445-3408
US

V. Phone/Fax

Practice location:
  • Phone: 231-719-1921
  • Fax: 231-719-9470
Mailing address:
  • Phone: 231-719-1921
  • Fax: 231-719-9470

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number5502005794
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: