Provider Demographics
NPI:1023511854
Name:MILES-ROLO, SANDRA MICHELLE (PT)
Entity type:Individual
Prefix:
First Name:SANDRA
Middle Name:MICHELLE
Last Name:MILES-ROLO
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2249 WEALTHY ST SE STE 120
Mailing Address - Street 2:
Mailing Address - City:EAST GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49506-3052
Mailing Address - Country:US
Mailing Address - Phone:616-325-9980
Mailing Address - Fax:
Practice Address - Street 1:2249 WEALTHY ST SE STE 120
Practice Address - Street 2:
Practice Address - City:EAST GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49506-3052
Practice Address - Country:US
Practice Address - Phone:616-391-4650
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-18
Last Update Date:2018-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501005247225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5501005247Medicaid