Provider Demographics
NPI:1972908929
Name:BOLEK, REBECCA (PT)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:
Last Name:BOLEK
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3384 PRAIRIE ST SW
Mailing Address - Street 2:
Mailing Address - City:GRANDVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:49418-1911
Mailing Address - Country:US
Mailing Address - Phone:616-719-1415
Mailing Address - Fax:
Practice Address - Street 1:3384 PRAIRIE ST SW
Practice Address - Street 2:
Practice Address - City:GRANDVILLE
Practice Address - State:MI
Practice Address - Zip Code:49418-1911
Practice Address - Country:US
Practice Address - Phone:616-719-1415
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-11-01
Last Update Date:2014-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501012877225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist