Provider Demographics
NPI:1396451563
Name:WOLTERS, MEGAN LEIGH (DPT)
Entity type:Individual
Prefix:
First Name:MEGAN
Middle Name:LEIGH
Last Name:WOLTERS
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7204 E GRAND RIVER AVE LOT 211
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:MI
Mailing Address - Zip Code:48875-8770
Mailing Address - Country:US
Mailing Address - Phone:616-822-3713
Mailing Address - Fax:
Practice Address - Street 1:6105 W ST JOE HWY STE 211
Practice Address - Street 2:
Practice Address - City:LANSING
Practice Address - State:MI
Practice Address - Zip Code:48917-4850
Practice Address - Country:US
Practice Address - Phone:888-619-9735
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-30
Last Update Date:2023-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501302316225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist