Basic Information
| Provider Information | |||||||||
| NPI: | 1659862845 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SYPERDA | ||||||||
| FirstName: | SARAH | ||||||||
| MiddleName: | MAE | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | PT, DPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1111 LEFFINGWELL AVE NE | ||||||||
| Address2: | |||||||||
| City: | GRAND RAPIDS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 495256406 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6164597101 | ||||||||
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| Practice Location | |||||||||
| Address1: | 625 KENMOOR AVE SE STE 306 | ||||||||
| Address2: | |||||||||
| City: | GRAND RAPIDS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 495462395 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6169425744 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/23/2018 | ||||||||
| LastUpdateDate: | 08/09/2019 | ||||||||
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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 | 5501017517 | MI | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 1306876438 | 05 | MI | MEDICAID |