Provider Demographics
NPI:1770608416
Name:WASSON, MICKEY CHARLES (PTA)
Entity type:Individual
Prefix:
First Name:MICKEY
Middle Name:CHARLES
Last Name:WASSON
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
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Mailing Address - Street 1:20123 NORTHVILLE PLACE DR
Mailing Address - Street 2:#2824
Mailing Address - City:NORTHVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:48167-2985
Mailing Address - Country:US
Mailing Address - Phone:989-657-1007
Mailing Address - Fax:269-651-2486
Practice Address - Street 1:228 W CHICAGO RD
Practice Address - Street 2:
Practice Address - City:STURGIS
Practice Address - State:MI
Practice Address - Zip Code:49091-1709
Practice Address - Country:US
Practice Address - Phone:269-651-2550
Practice Address - Fax:269-651-2486
Is Sole Proprietor?:No
Enumeration Date:2007-03-20
Last Update Date:2007-07-08
Deactivation Date:
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Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant