Healthcare Provider Details

I. General information

NPI: 1689791014
Provider Name (Legal Business Name): MARY-TERESA GERALYN FLETTER M.S.P.T.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MARY-TERESA GERALYN STENGER

II. Dates (important events)

Enumeration Date: 03/22/2007
Last Update Date: 05/24/2021
Certification Date: 05/24/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1423 W CENTRE AVE
PORTAGE MI
49024-5351
US

IV. Provider business mailing address

PO BOX 412031
BOSTON MA
02241-2031
US

V. Phone/Fax

Practice location:
  • Phone: 269-323-4300
  • Fax: 269-323-4449
Mailing address:
  • Phone: 914-294-4050
  • Fax: 631-760-8306

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number5501009829
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: