=====================================================
General NPI Number Information
=====================================================
NPI Number | 1063229896
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ERIKA MARIE COOLEY DPT
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/16/2024
-----------------------------------------------------
Last Update Date | 12/16/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1423 60TH ST SE
-----------------------------------------------------
City | KENTWOOD
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49508-7065
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 616-455-3535
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4951 OAKWAY CT NE
-----------------------------------------------------
City | GRAND RAPIDS
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49525-6836
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 303-324-3336
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2251X0800X
-----------------------------------------------------
Taxonomy Name | Orthopedic Physical Therapist
-----------------------------------------------------
License Number | 5501302704
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------