Healthcare Provider Details

I. General information

NPI: 1508365669
Provider Name (Legal Business Name): JUSTIN WIGHT DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/05/2018
Last Update Date: 05/28/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

281 ENTERPRISE CT STE 200
BLOOMFIELD HILLS MI
48302-0311
US

IV. Provider business mailing address

33900 HARPER AVE STE 104
CLINTON TWP MI
48035-4258
US

V. Phone/Fax

Practice location:
  • Phone: 248-322-5280
  • Fax: 248-333-1915
Mailing address:
  • Phone: 586-350-2644
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number5501018569
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: