Provider Demographics
NPI:1598552853
Name:ALLIS, MARY
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:ALLIS
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2067 WOODBURN DR SE APT 10
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49546-4378
Mailing Address - Country:US
Mailing Address - Phone:616-550-5427
Mailing Address - Fax:
Practice Address - Street 1:2067 WOODBURN DR SE APT 10
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49546-4378
Practice Address - Country:US
Practice Address - Phone:616-550-5427
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-04-21
Last Update Date:2025-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI60068225800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225800000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRecreation Therapist