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General NPI Number Information
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NPI Number | 1972908085
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Entity Type | Organization
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Legal Business Name | DIVERSIFIED PT
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Dates
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Enumeration Date | 10/31/2014
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Last Update Date | 10/31/2014
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Provider Practice Location Address
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Address Line | 1635 W SHERMAN BLVD
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City | NORTON SHORES
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State | MI
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Zip | 49441-3544
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Country | US
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Telephone | 231-755-4404
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Fax |
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Provider Business Mailing Address
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Address Line | 1635 W SHERMAN BLVD
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City | NORTON SHORES
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State | MI
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Zip | 49441-3544
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Country | US
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Telephone | 231-755-4404
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Fax |
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Authorized Official
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Title or Position | PHYSICAL THERAPIST
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Name | MRS. DEBORAH ANN HANSON
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Credential | MSPT
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Telephone | 231-755-4404
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QP2000X
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Taxonomy Name | Physical Therapy Clinic/Center
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License Number | 5502001290
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License Number State | MI
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