Healthcare Provider Details

I. General information

NPI: 1578785242
Provider Name (Legal Business Name): PAMELA SUE KNICKERBOCKER PT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/03/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

325 E EISENHOWER PKWY 2ND FLOOR
ANN ARBOR MI
48108-3364
US

IV. Provider business mailing address

8456 PONTIAC TRL
SOUTH LYON MI
48178-7018
US

V. Phone/Fax

Practice location:
  • Phone: 734-763-4797
  • Fax: 734-763-3715
Mailing address:
  • Phone: 734-763-4797
  • Fax: 734-763-3715

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2251X0800X
TaxonomyOrthopedic Physical Therapist
License Number5501003010
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: