Healthcare Provider Details

I. General information

NPI: 1104548379
Provider Name (Legal Business Name): ULTIMATE POTENTIAL THERAPY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/14/2022
Last Update Date: 09/14/2022
Certification Date: 09/14/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5472 WHISPERING PNES
STEVENSVILLE MI
49127-9674
US

IV. Provider business mailing address

5472 WHISPERING PNES
STEVENSVILLE MI
49127-9674
US

V. Phone/Fax

Practice location:
  • Phone: 216-409-0239
  • Fax:
Mailing address:
  • Phone: 216-409-0239
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: JESSICA BRICKMAN
Title or Position: SPEECH LANGUAGE PATHOLOGIST
Credential: M.S. CCC-SLP
Phone: 216-409-0239