Provider Demographics
NPI:1043714769
Name:BELLNER-FONGERS, BETH
Entity Type:Individual
Prefix:
First Name:BETH
Middle Name:
Last Name:BELLNER-FONGERS
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 1:515 E DIVISION ST
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:MI
Mailing Address - Zip Code:49341-1377
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:515 E DIVISION ST
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:MI
Practice Address - Zip Code:49341-1377
Practice Address - Country:US
Practice Address - Phone:616-863-3133
Practice Address - Fax:616-866-8973
Is Sole Proprietor?:No
Enumeration Date:2018-03-19
Last Update Date:2018-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501004039225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist