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General NPI Number Information
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NPI Number | 1326811076
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Entity Type | Organization
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Legal Business Name | MARA GOSEN PT, DPT LLC
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Dates
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Enumeration Date | 11/03/2023
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Last Update Date | 04/21/2024
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Provider Practice Location Address
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Address Line | 36 DWIGHT AVE SE UNIT 2
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City | GRAND RAPIDS
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State | MI
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Zip | 49506-1436
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Country | US
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Telephone | 989-860-8397
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Fax |
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Provider Business Mailing Address
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Address Line | 36 DWIGHT AVE SE UNIT 2
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City | GRAND RAPIDS
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State | MI
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Zip | 49506-1436
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | OWNER/PHYSICAL THERAPIST
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Name | MARA GOSEN
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Credential |
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Telephone | 989-860-8397
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225100000X
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Taxonomy Name | Physical Therapist
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License Number |
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License Number State |
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