Provider Demographics
NPI:1801387477
Name:HOUSEHOLDER, RICHARD W (PTA)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:W
Last Name:HOUSEHOLDER
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:28 CAMPBELL ST
Mailing Address - Street 2:
Mailing Address - City:HOLLAND
Mailing Address - State:MI
Mailing Address - Zip Code:49424-2127
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:243 WILEY RD
Practice Address - Street 2:
Practice Address - City:DOUGLAS
Practice Address - State:MI
Practice Address - Zip Code:49406-5108
Practice Address - Country:US
Practice Address - Phone:269-857-2141
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-19
Last Update Date:2018-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant