Healthcare Provider Details

I. General information

NPI: 1275119646
Provider Name (Legal Business Name): VICTORIA TERRY MPT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

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

III. Provider practice location address

777 GOGUAC ST W STE B2
SPRINGFIELD MI
49015-2097
US

IV. Provider business mailing address

777 GOGUAC ST W STE B2
SPRINGFIELD MI
49015-2097
US

V. Phone/Fax

Practice location:
  • Phone: 269-223-7786
  • Fax:
Mailing address:
  • Phone: 269-223-7786
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2251P0200X
TaxonomyPediatric Physical Therapist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: