Provider Demographics
NPI:1609360619
Name:BETTELEY, JONATHAN GRANT (MPT)
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:GRANT
Last Name:BETTELEY
Suffix:
Gender:M
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 WILLIAM CARLS DR
Mailing Address - Street 2:
Mailing Address - City:COMMERCE TOWNSHIP
Mailing Address - State:MI
Mailing Address - Zip Code:48382-2201
Mailing Address - Country:US
Mailing Address - Phone:248-937-3456
Mailing Address - Fax:248-937-3458
Practice Address - Street 1:1 WILLIAM CARLS DR
Practice Address - Street 2:
Practice Address - City:COMMERCE TOWNSHIP
Practice Address - State:MI
Practice Address - Zip Code:48382-2201
Practice Address - Country:US
Practice Address - Phone:248-937-3456
Practice Address - Fax:248-937-3458
Is Sole Proprietor?:No
Enumeration Date:2018-06-22
Last Update Date:2018-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501010486225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist