Provider Demographics
NPI:1003778721
Name:FELICZAK, JUSTIN THOMAS
Entity type:Individual
Prefix:
First Name:JUSTIN
Middle Name:THOMAS
Last Name:FELICZAK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3205 SOFT WATER LAKE DR NE APT 9-204
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49525-2748
Mailing Address - Country:US
Mailing Address - Phone:231-510-5079
Mailing Address - Fax:231-510-5079
Practice Address - Street 1:400 JEFFREY ST
Practice Address - Street 2:
Practice Address - City:CEDAR SPRINGS
Practice Address - State:MI
Practice Address - Zip Code:49319-9572
Practice Address - Country:US
Practice Address - Phone:616-696-0170
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-12-01
Last Update Date:2025-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant