MEDICARE: KELLY GOTBERG PT, DPT

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	2251X0800X	Orthopedic Physical Therapist	5501018868	MI

General Provider Information

NPI Number	:	1265916852
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KELLY GOTBERG PT, DPT

Provider Business Mailing Address
First Line	:	5380 LAKE MICHIGAN DR
Second Line	:
City	:	ALLENDALE
State	:	MI
Zip	:	49401-9484
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	854 WASHINGTON AVE STE 200
Second Line	:
City	:	HOLLAND
State	:	MI
Zip	:	49423-7143
Country	:	US
Telephone Number	:	616-392-9430
Fax Number	:

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

Provider Enumeration Date	:	09/19/2018
Last Update Date	:	09/19/2018

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Directions to “ KELLY GOTBERG PT, DPT” Practice Location

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