Provider Demographics
NPI:1851876064
Name:GRUDZINSKAS, MATTHEW (PTA)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:
Last Name:GRUDZINSKAS
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 1:4637 RIVERA CT SW
Mailing Address - Street 2:
Mailing Address - City:GRANDVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:49418-9259
Mailing Address - Country:US
Mailing Address - Phone:616-634-6507
Mailing Address - Fax:
Practice Address - Street 1:2500 E BELTLINE AVE SE STE J
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49546-5987
Practice Address - Country:US
Practice Address - Phone:616-855-6588
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-03
Last Update Date:2023-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5502005248225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant