Healthcare Provider Details

I. General information

NPI: 1174643613
Provider Name (Legal Business Name): KAREN ANN WALLIS PHYSICAL THERAPIST
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/29/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2665 SHEFMAN TER
ANN ARBOR MI
48105-3441
US

IV. Provider business mailing address

430 3RD ST
ANN ARBOR MI
48103-4902
US

V. Phone/Fax

Practice location:
  • Phone: 734-973-6473
  • Fax:
Mailing address:
  • Phone: 734-665-0486
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberMI001945
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: