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General NPI Number Information
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NPI Number | 1649476789
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Entity Type | Individual
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Provider Name | JOANNE KAREN ICKSTADT P.T.
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Gender | Female
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Dates
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Enumeration Date | 06/25/2007
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Last Update Date | 07/08/2007
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Provider Practice Location Address
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Address Line | 2900 CHARLEVOIX DR SE SUITE #200
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City | GRAND RAPIDS
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State | MI
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Zip | 49546-7085
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Country | US
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Telephone | 800-634-1077
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Fax |
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Provider Business Mailing Address
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Address Line | 860 3 CRABS RD
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City | SEQUIM
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State | WA
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Zip | 98382-7852
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Country | US
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Telephone | 719-510-6420
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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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 | PT00010467
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License Number State | WA
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