Provider Demographics
NPI:1093487639
Name:BOLLING, CYNTHIA ANN (LPTA)
Entity Type:Individual
Prefix:
First Name:CYNTHIA
Middle Name:ANN
Last Name:BOLLING
Suffix:
Gender:F
Credentials:LPTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15643 LITTLEFIELD LN
Mailing Address - Street 2:
Mailing Address - City:SPRING LAKE
Mailing Address - State:MI
Mailing Address - Zip Code:49456-1129
Mailing Address - Country:US
Mailing Address - Phone:616-340-2345
Mailing Address - Fax:
Practice Address - Street 1:900 S BEACON BLVD
Practice Address - Street 2:
Practice Address - City:GRAND HAVEN
Practice Address - State:MI
Practice Address - Zip Code:49417-2146
Practice Address - Country:US
Practice Address - Phone:616-296-7300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-01
Last Update Date:2021-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5502004289225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant