MEDICARE: LIFESPAN THERAPY & WELLNESS, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225100000X	Physical Therapist	5501010802	MI
2	225100000X	Physical Therapist	5501010889	MI
3	225100000X	Physical Therapist	5501010900	MI

General Provider Information

NPI Number	:	1669626289
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LIFESPAN THERAPY & WELLNESS, LLC

Provider Business Mailing Address
First Line	:	PO BOX 567
Second Line	:
City	:	WASHINGTON
State	:	MI
Zip	:	48094-0567
Country	:	US
Telephone Number	:	248-765-3153
Fax Number	:

Provider Business Practice Location Address
First Line	:	7457 SAWGRESS DR
Second Line	:
City	:	WASHINGTON TOWNSHIP
State	:	MI
Zip	:	48094
Country	:	US
Telephone Number	:	248-765-3153
Fax Number	:

Authorized Official
Title or Position	:	CO-OWNER
Name	:	MRS. KATHERINE MARY WYBO
Credential	:	M.P.T.
Telephone Number	:	248-765-3153

Provider Enumeration Date	:	11/10/2008
Last Update Date	:	12/29/2008

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