Provider Demographics
NPI:1609069244
Name:KISHMAN, EILEEN MARIE (PT)
Entity Type:Individual
Prefix:MRS
First Name:EILEEN
Middle Name:MARIE
Last Name:KISHMAN
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:EILEEN
Other - Middle Name:MARIE
Other - Last Name:KENNEDY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:PO BOX 30516
Mailing Address - Street 2:DEPT 5300
Mailing Address - City:LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48909
Mailing Address - Country:US
Mailing Address - Phone:616-356-5000
Mailing Address - Fax:
Practice Address - Street 1:5340 PLAZA AVE
Practice Address - Street 2:SUITE 3
Practice Address - City:HUDSONVILLE
Practice Address - State:MI
Practice Address - Zip Code:49426
Practice Address - Country:US
Practice Address - Phone:616-608-8922
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-08-27
Last Update Date:2022-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501003198225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1609069244OtherNPI
MI650G013740OtherBCBSM
MI5501003198OtherMICHIGAN STATE LICENSE
MI1609069244OtherNPI
MIP38990003Medicare PIN
MIP04810011Medicare PIN