Basic Information
| Provider Information | |||||||||
| NPI: | 1164027199 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BOCKETTI | ||||||||
| FirstName: | MARIAH | ||||||||
| MiddleName: | KATHRYN | ||||||||
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| Credential: | PT, DPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4285 DEVELOPMENT DRIVE | ||||||||
| Address2: | |||||||||
| City: | LANSING | ||||||||
| State: | MI | ||||||||
| PostalCode: | 48911 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5177060421 | ||||||||
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| Practice Location | |||||||||
| Address1: | 4285 DEVELOPMENT DRIVE | ||||||||
| Address2: | |||||||||
| City: | LANSING | ||||||||
| State: | MI | ||||||||
| PostalCode: | 48911 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5177060421 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/30/2020 | ||||||||
| LastUpdateDate: | 05/06/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/08/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2251P0200X | 5501019840 | MI | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | Pediatrics |
No ID Information.