Provider Demographics
NPI:1790498087
Name:MINGLEDORFF, CATHERINE
Entity Type:Individual
Prefix:
First Name:CATHERINE
Middle Name:
Last Name:MINGLEDORFF
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:BETH
Other - Middle Name:
Other - Last Name:MINGLEDORFF
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:653 SPENCER ST NE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49505-5207
Mailing Address - Country:US
Mailing Address - Phone:773-251-5960
Mailing Address - Fax:
Practice Address - Street 1:233 FULTON ST E STE 210E
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49503-3261
Practice Address - Country:US
Practice Address - Phone:616-425-9550
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-02
Last Update Date:2023-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI7501011507225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist