Provider Demographics
NPI:1689085664
Name:FUKUDA, CHELSIE
Entity Type:Individual
Prefix:
First Name:CHELSIE
Middle Name:
Last Name:FUKUDA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:CHELSIE
Other - Middle Name:
Other - Last Name:KOHOUT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:38155 CIRCLE DR
Mailing Address - Street 2:
Mailing Address - City:HARRISON TWP
Mailing Address - State:MI
Mailing Address - Zip Code:48045-2816
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:38155 CIRCLE DR
Practice Address - Street 2:
Practice Address - City:HARRISON TWP
Practice Address - State:MI
Practice Address - Zip Code:48045-2816
Practice Address - Country:US
Practice Address - Phone:586-212-3603
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-05-13
Last Update Date:2021-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501016737225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist