Provider Demographics
NPI:1699061655
Name:PRZYSTAS, RENEE M (DPT)
Entity type:Individual
Prefix:MRS
First Name:RENEE
Middle Name:M
Last Name:PRZYSTAS
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:RENEE
Other - Middle Name:MARIE
Other - Last Name:AUERNHAMER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DPT
Mailing Address - Street 1:18000 COVE STREET
Mailing Address - Street 2:SUITE 202
Mailing Address - City:SPRING LAKE
Mailing Address - State:MI
Mailing Address - Zip Code:49456-1383
Mailing Address - Country:US
Mailing Address - Phone:616-847-1280
Mailing Address - Fax:616-847-1290
Practice Address - Street 1:18000 COVE STREET
Practice Address - Street 2:SUITE 202
Practice Address - City:SPRING LAKE
Practice Address - State:MI
Practice Address - Zip Code:49456-1383
Practice Address - Country:US
Practice Address - Phone:616-847-1280
Practice Address - Fax:616-847-1290
Is Sole Proprietor?:No
Enumeration Date:2011-06-28
Last Update Date:2016-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501015617225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5501015617OtherLICENSE NUMBER
MIP14760012Medicare PIN