Provider Demographics
NPI:1770085557
Name:BOGARD, ILSE MICHELLE (PT,DPT)
Entity type:Individual
Prefix:
First Name:ILSE
Middle Name:MICHELLE
Last Name:BOGARD
Suffix:
Gender:F
Credentials:PT,DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1320 W STATE ST STE 3D
Mailing Address - Street 2:
Mailing Address - City:BELDING
Mailing Address - State:MI
Mailing Address - Zip Code:48809-9245
Mailing Address - Country:US
Mailing Address - Phone:616-244-1110
Mailing Address - Fax:
Practice Address - Street 1:1320 W STATE ST STE 3D
Practice Address - Street 2:
Practice Address - City:BELDING
Practice Address - State:MI
Practice Address - Zip Code:48809-9245
Practice Address - Country:US
Practice Address - Phone:616-244-1110
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-07
Last Update Date:2018-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501016833225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist