Provider Demographics
NPI:1467204008
Name:WILLERER, MADELIN ROSE (MS, ATC)
Entity Type:Individual
Prefix:
First Name:MADELIN
Middle Name:ROSE
Last Name:WILLERER
Suffix:
Gender:F
Credentials:MS, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2591 44TH ST SE STE 101
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49512-9094
Mailing Address - Country:US
Mailing Address - Phone:616-281-9237
Mailing Address - Fax:
Practice Address - Street 1:6230 KALAMAZOO AVE SE
Practice Address - Street 2:
Practice Address - City:KENTWOOD
Practice Address - State:MI
Practice Address - Zip Code:49508-7022
Practice Address - Country:US
Practice Address - Phone:616-698-6700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-04-05
Last Update Date:2024-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI26010022532255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer