MEDICARE: JUSTIN THOMAS FELICZAK

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	224Z00000X	Occupational Therapy Assistant

General Provider Information

NPI Number	:	1003778721
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JUSTIN THOMAS FELICZAK

Provider Business Mailing Address
First Line	:	3205 SOFT WATER LAKE DR NE APT 9-204
Second Line	:
City	:	GRAND RAPIDS
State	:	MI
Zip	:	49525-2748
Country	:	US
Telephone Number	:	231-510-5079
Fax Number	:	231-510-5079

Provider Business Practice Location Address
First Line	:	400 JEFFREY ST
Second Line	:
City	:	CEDAR SPRINGS
State	:	MI
Zip	:	49319-9572
Country	:	US
Telephone Number	:	616-696-0170
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/01/2025
Last Update Date	:	12/01/2025

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Directions to “ JUSTIN THOMAS FELICZAK ” Practice Location

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