Healthcare Provider Details

I. General information

NPI: 1376816991
Provider Name (Legal Business Name): IDA MARIE TROTT DPT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/13/2012
Last Update Date: 11/05/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2215 FULLER RD
ANN ARBOR MI
48105-2303
US

IV. Provider business mailing address

7076 RUNYAN LAKE RD
FENTON MI
48430-9314
US

V. Phone/Fax

Practice location:
  • Phone: 734-845-3792
  • Fax:
Mailing address:
  • Phone: 810-877-9554
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2251N0400X
TaxonomyNeurology Physical Therapist
License Number5501010685
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: