Provider Demographics
NPI:1275051153
Name:BAZAN, CHERYL DIANE (PT, DPT, CKTP)
Entity Type:Individual
Prefix:
First Name:CHERYL
Middle Name:DIANE
Last Name:BAZAN
Suffix:
Gender:F
Credentials:PT, DPT, CKTP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3075 ORCHARD VISTA DR SE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49546-7069
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3075 ORCHARD VISTA DR SE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49546-7069
Practice Address - Country:US
Practice Address - Phone:616-301-8000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-31
Last Update Date:2017-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501015926225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist