Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225100000X | Physical Therapist | 5501004011 | MI |
N | 225700000X | Massage Therapist | 406631-00 | MI |
NPI | 1013963206 |
---|---|
Provider Name | Peggy A Ivan |
First Address | Freeland, MI 48623-9111 |
Second Address | Freeland, MI 48623-9111 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 26/05/2006 |
Last Update Date | 09/02/2012 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
P97408 | (02) | MI |