Basic Information
| Provider Information | |||||||||
| NPI: | 1629136122 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LECLAIRE | ||||||||
| FirstName: | AMY | ||||||||
| MiddleName: | M | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.S.P.T., A.T., C. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | ZYCK | ||||||||
| OtherFirstName: | AMY | ||||||||
| OtherMiddleName: | M | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1111 LEFFINGWELL AVE NE | ||||||||
| Address2: | |||||||||
| City: | GRAND RAPIDS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 495256406 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6164597101 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 5060 CASCADE RD SE | ||||||||
| Address2: | SUITE A | ||||||||
| City: | GRAND RAPIDS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 495463808 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6169540950 | ||||||||
| FaxNumber: | 6169541728 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/05/2006 | ||||||||
| LastUpdateDate: | 08/08/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 5501012959 | MI | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.