Healthcare Provider Details

I. General information

NPI: 1790381721
Provider Name (Legal Business Name): PEDIATRIC REHAB SPECIALISTS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/06/2020
Last Update Date: 01/27/2021
Certification Date: 01/27/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2381 LOST TREE WAY
BLOOMFIELD HILLS MI
48304-1474
US

IV. Provider business mailing address

2381 LOST TREE WAY
BLOOMFIELD HILLS MI
48304-1474
US

V. Phone/Fax

Practice location:
  • Phone: 248-797-2005
  • Fax:
Mailing address:
  • Phone: 248-797-2005
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2251P0200X
TaxonomyPediatric Physical Therapist
License Number
License Number State

VIII. Authorized Official

Name: WENDY ZAJAC
Title or Position: OWNER
Credential:
Phone: 248-797-2005