Healthcare Provider Details

I. General information

NPI: 1528500253
Provider Name (Legal Business Name): NICOLE ANGLEBRANDT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/11/2016
Last Update Date: 11/11/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 FORT ST
PORT HURON MI
48060-3941
US

IV. Provider business mailing address

33900 HARPER AVE SUITE 104
CLINTON TOWNSHIP MI
48035-4258
US

V. Phone/Fax

Practice location:
  • Phone: 586-987-9711
  • Fax: 586-987-6070
Mailing address:
  • Phone: 586-416-9100
  • Fax: 586-416-9103

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number5502005020
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: