Provider Demographics
NPI:1275583031
Name:KIRSTEN, MARJALIZE (PT)
Entity Type:Individual
Prefix:MISS
First Name:MARJALIZE
Middle Name:
Last Name:KIRSTEN
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8087 BURLINGAME AVE SW
Mailing Address - Street 2:
Mailing Address - City:BYRON CENTER
Mailing Address - State:MI
Mailing Address - Zip Code:49315-9334
Mailing Address - Country:US
Mailing Address - Phone:616-405-1085
Mailing Address - Fax:
Practice Address - Street 1:3584 FAIRLANES AVE SW
Practice Address - Street 2:
Practice Address - City:GRANDVILLE
Practice Address - State:MI
Practice Address - Zip Code:49418-1583
Practice Address - Country:US
Practice Address - Phone:616-531-5025
Practice Address - Fax:616-531-5027
Is Sole Proprietor?:No
Enumeration Date:2006-05-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501006886225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist