Provider Demographics
NPI:1679913776
Name:VANTASSEL, LOWELL M (PT)
Entity Type:Individual
Prefix:
First Name:LOWELL
Middle Name:M
Last Name:VANTASSEL
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:L
Other - Middle Name:MARK
Other - Last Name:VANTASSEL
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PT
Mailing Address - Street 1:205 OSCEOLA ST
Mailing Address - Street 2:
Mailing Address - City:LAURIUM
Mailing Address - State:MI
Mailing Address - Zip Code:49913-2134
Mailing Address - Country:US
Mailing Address - Phone:906-337-6500
Mailing Address - Fax:906-337-6597
Practice Address - Street 1:960 RAZORBACK DR STE 3
Practice Address - Street 2:
Practice Address - City:HOUGHTON
Practice Address - State:MI
Practice Address - Zip Code:49931-2830
Practice Address - Country:US
Practice Address - Phone:906-482-8201
Practice Address - Fax:906-482-2771
Is Sole Proprietor?:No
Enumeration Date:2013-07-03
Last Update Date:2013-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501002464225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist