=====================================================
General NPI Number Information
=====================================================
NPI Number | 1649984030
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CASSANDRA COATNEY DPT
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/10/2023
-----------------------------------------------------
Last Update Date | 03/12/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 345 FULLER AVE NE SUITE 1
-----------------------------------------------------
City | GRAND RAPIDS
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49503
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 616-608-8938
-----------------------------------------------------
Fax | 616-410-7790
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 30516 DEPT 5300
-----------------------------------------------------
City | LANSING
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48909
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 630-575-1980
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number | 5501302418
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------