Provider Demographics
NPI:1154898344
Name:BORMAN, JUSTIN ANTHONY (PTA)
Entity type:Individual
Prefix:
First Name:JUSTIN
Middle Name:ANTHONY
Last Name:BORMAN
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2815 MOORE RD
Mailing Address - Street 2:
Mailing Address - City:BAILEY
Mailing Address - State:MI
Mailing Address - Zip Code:49303-9604
Mailing Address - Country:US
Mailing Address - Phone:719-452-9952
Mailing Address - Fax:
Practice Address - Street 1:5429 NORTHLAND DR NE STE A
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49525-1089
Practice Address - Country:US
Practice Address - Phone:616-855-0540
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-26
Last Update Date:2021-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5502005756225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant