Provider Demographics
NPI:1043707169
Name:MATT, MINDY LEE
Entity Type:Individual
Prefix:MS
First Name:MINDY
Middle Name:LEE
Last Name:MATT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7245 THORNAPPLE HOLLOW DR SE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49546-9695
Mailing Address - Country:US
Mailing Address - Phone:616-304-6380
Mailing Address - Fax:616-304-6380
Practice Address - Street 1:5900 BYRON CENTER AVE SW
Practice Address - Street 2:
Practice Address - City:WYOMING
Practice Address - State:MI
Practice Address - Zip Code:49519-9686
Practice Address - Country:US
Practice Address - Phone:616-252-7199
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-14
Last Update Date:2018-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501009018225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist