Healthcare Provider Details

I. General information

NPI: 1679902183
Provider Name (Legal Business Name): MICHELLE STEVENS PTA/L
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/05/2013
Last Update Date: 10/26/2020
Certification Date: 10/26/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2786 56TH ST SW
WYOMING MI
49418-8708
US

IV. Provider business mailing address

2000 32ND ST SE
GRAND RAPIDS MI
49508-7910
US

V. Phone/Fax

Practice location:
  • Phone: 616-261-3960
  • Fax: 616-261-3925
Mailing address:
  • Phone: 616-261-3960
  • Fax: 616-261-3925

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberL2263382
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: