Provider Demographics
NPI:1760039291
Name:DEN ENGELSE, KORSTIAAN (PT)
Entity Type:Individual
Prefix:
First Name:KORSTIAAN
Middle Name:
Last Name:DEN ENGELSE
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:ARKO
Other - Middle Name:
Other - Last Name:DEN ENGELSE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PT
Mailing Address - Street 1:2535 W WOODROW RD
Mailing Address - Street 2:
Mailing Address - City:SHELBY
Mailing Address - State:MI
Mailing Address - Zip Code:49455-8627
Mailing Address - Country:US
Mailing Address - Phone:231-861-8930
Mailing Address - Fax:
Practice Address - Street 1:3097 PRAIRIE ST SW
Practice Address - Street 2:
Practice Address - City:GRANDVILLE
Practice Address - State:MI
Practice Address - Zip Code:49418-2000
Practice Address - Country:US
Practice Address - Phone:616-531-9973
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-20
Last Update Date:2019-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
225100000X
MI5501006325225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty