Provider Demographics
NPI:1679130165
Name:BARTRUM, MARIAH LINN (PTA)
Entity Type:Individual
Prefix:
First Name:MARIAH
Middle Name:LINN
Last Name:BARTRUM
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:MARIAH
Other - Middle Name:
Other - Last Name:GUNN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:61606 SHERMAN LN
Mailing Address - Street 2:
Mailing Address - City:CASSOPOLIS
Mailing Address - State:MI
Mailing Address - Zip Code:49031-8717
Mailing Address - Country:US
Mailing Address - Phone:574-612-3816
Mailing Address - Fax:
Practice Address - Street 1:23770 HOSPITAL ST
Practice Address - Street 2:
Practice Address - City:CASSOPOLIS
Practice Address - State:MI
Practice Address - Zip Code:49031-9699
Practice Address - Country:US
Practice Address - Phone:269-445-3801
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-21
Last Update Date:2019-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5502004913225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant