MEDICARE: SUE ELLEN UGLIETTA MPT

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	225100000X	Physical Therapist	5501012000	MI

General Provider Information

NPI Number	:	1023415080
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SUE ELLEN UGLIETTA MPT

Provider Business Mailing Address
First Line	:	2816 E BELTLINE LN NE
Second Line	:
City	:	GRAND RAPIDS
State	:	MI
Zip	:	49525-9432
Country	:	US
Telephone Number	:	616-361-1210
Fax Number	:	616-361-8662

Provider Business Practice Location Address
First Line	:	2816 E BELTLINE LN NE
Second Line	:
City	:	GRAND RAPIDS
State	:	MI
Zip	:	49525-9432
Country	:	US
Telephone Number	:	616-361-1210
Fax Number	:	616-361-8662

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

Provider Enumeration Date	:	11/19/2014
Last Update Date	:	11/19/2014

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