Healthcare Provider Details

I. General information

NPI: 1104544535
Provider Name (Legal Business Name): MR. ROBERT LEE LIPSEY JR.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/22/2022
Last Update Date: 06/16/2026
Certification Date: 06/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

501 GRAHAM AVE
BENTON HARBOR MI
49022-3626
US

IV. Provider business mailing address

501 GRAHAM AVE
BENTON HARBOR MI
49022-3626
US

V. Phone/Fax

Practice location:
  • Phone: 269-769-6108
  • Fax: 269-934-5054
Mailing address:
  • Phone: 269-769-6108
  • Fax: 269-934-5054

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number5501304569
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: