Provider Demographics
NPI:1487046892
Name:HARLESS, MIKAELA GRACE (DPT)
Entity type:Individual
Prefix:
First Name:MIKAELA
Middle Name:GRACE
Last Name:HARLESS
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:MIKAELA
Other - Middle Name:GRACE
Other - Last Name:HARRELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:18000 COVE ST STE 202
Mailing Address - Street 2:
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 1:890 WASHINGTON AVE STE 130A
Practice Address - Street 2:
Practice Address - City:HOLLAND
Practice Address - State:MI
Practice Address - Zip Code:49423-7731
Practice Address - Country:US
Practice Address - Phone:616-994-8136
Practice Address - Fax:616-994-8162
Is Sole Proprietor?:Yes
Enumeration Date:2015-02-21
Last Update Date:2023-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501301749225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty