Provider Demographics
NPI:1881991354
Name:VERZOSA-MINA, ELEANOR R (PT)
Entity type:Individual
Prefix:
First Name:ELEANOR
Middle Name:R
Last Name:VERZOSA-MINA
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 1:555 N BRADLEY HWY
Mailing Address - Street 2:SUIITE D
Mailing Address - City:ROGERS CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49779-1539
Mailing Address - Country:US
Mailing Address - Phone:989-734-2151
Mailing Address - Fax:989-734-7648
Practice Address - Street 1:555 N BRADLEY HWY
Practice Address - Street 2:SUIITE D
Practice Address - City:ROGERS CITY
Practice Address - State:MI
Practice Address - Zip Code:49779-1539
Practice Address - Country:US
Practice Address - Phone:989-734-2151
Practice Address - Fax:989-734-7648
Is Sole Proprietor?:No
Enumeration Date:2011-02-18
Last Update Date:2015-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501011903225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5501011903OtherPHYSICAL THERAPIST