Healthcare Provider Details

I. General information

NPI: 1093626640
Provider Name (Legal Business Name): TESSA ANNE KRETOWICZ PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/14/2026
Last Update Date: 09/14/2026
Certification Date: 09/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2101 52ND ST SW
WYOMING MI
49519-9613
US

IV. Provider business mailing address

2101 HOUSEMAN AVE NE
GRAND RAPIDS MI
49505-4341
US

V. Phone/Fax

Practice location:
  • Phone: 303-828-8417
  • Fax:
Mailing address:
  • Phone: 616-301-6191
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number5502003831
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: