Provider Demographics
NPI:1184454159
Name:HENTSCHEL, CLARISSA MICHELLE
Entity type:Individual
Prefix:MISS
First Name:CLARISSA
Middle Name:MICHELLE
Last Name:HENTSCHEL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:411 122ND AVE
Mailing Address - Street 2:
Mailing Address - City:SHELBYVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:49344-9755
Mailing Address - Country:US
Mailing Address - Phone:269-251-6728
Mailing Address - Fax:
Practice Address - Street 1:4150 KALAMAZOO AVE SE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49508-3605
Practice Address - Country:US
Practice Address - Phone:616-913-2006
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-08-05
Last Update Date:2024-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5502008620225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5502008620Medicaid