Provider Demographics
NPI:1972023471
Name:FENNER, MAIJA MATINTYTAR
Entity type:Individual
Prefix:
First Name:MAIJA
Middle Name:MATINTYTAR
Last Name:FENNER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6512 WELLMAN LINE RD
Mailing Address - Street 2:
Mailing Address - City:CROSWELL
Mailing Address - State:MI
Mailing Address - Zip Code:48422-9120
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6512 WELLMAN LINE RD
Practice Address - Street 2:
Practice Address - City:CROSWELL
Practice Address - State:MI
Practice Address - Zip Code:48422-9120
Practice Address - Country:US
Practice Address - Phone:810-278-7514
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-26
Last Update Date:2017-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501013810225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist