Provider Demographics
NPI:1356849665
Name:GOVITZ, JEFFERY RYAN
Entity Type:Individual
Prefix:
First Name:JEFFERY
Middle Name:RYAN
Last Name:GOVITZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1500 W HIGH ST
Mailing Address - Street 2:
Mailing Address - City:MT PLEASANT
Mailing Address - State:MI
Mailing Address - Zip Code:48858-3028
Mailing Address - Country:US
Mailing Address - Phone:989-772-0258
Mailing Address - Fax:
Practice Address - Street 1:1500 W HIGH ST
Practice Address - Street 2:
Practice Address - City:MT PLEASANT
Practice Address - State:MI
Practice Address - Zip Code:48858-3028
Practice Address - Country:US
Practice Address - Phone:989-772-0258
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-01
Last Update Date:2018-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5502004595225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant