Provider Demographics
NPI:1891269429
Name:PRIESE, TONYA RENE (PTA)
Entity Type:Individual
Prefix:MS
First Name:TONYA
Middle Name:RENE
Last Name:PRIESE
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2526 RAY AVE
Mailing Address - Street 2:
Mailing Address - City:NEW ERA
Mailing Address - State:MI
Mailing Address - Zip Code:49446-9641
Mailing Address - Country:US
Mailing Address - Phone:231-301-9518
Mailing Address - Fax:
Practice Address - Street 1:111 LAKESIDE DR NE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49503-3811
Practice Address - Country:US
Practice Address - Phone:616-588-1645
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-16
Last Update Date:2019-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5502004698225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant