Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 2251G0304X | Physical Therapist - Geriatrics |
NPI | 1184196792 |
---|---|
Provider Name | Alicia Adams |
First Address | Grand Rapids, MI 49546-5783 |
Second Address | Caledonia, MI 49316-7309 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 20/12/2018 |
Last Update Date | 20/12/2018 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
5501016773 | (05) | MI |