=====================================================
General NPI Number Information
=====================================================
NPI Number | 1700121068
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LEAH MARIE BARTOLAMEOLLI
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/27/2012
-----------------------------------------------------
Last Update Date | 11/30/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 212 S SULLIVAN AVE
-----------------------------------------------------
City | FREMONT
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49412
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 231-924-1379
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 212 S SULLIVAN AVE
-----------------------------------------------------
City | FREMONT
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49412-1548
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 231-924-1379
-----------------------------------------------------
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 | 5501010892
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------