Healthcare Provider Details

I. General information

NPI: 1619124138
Provider Name (Legal Business Name): MARY K. YEAGER P.T
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/27/2008
Last Update Date: 08/09/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

49650 CHERRY HILL RD SUITE 230
CANTON MI
48187-4849
US

IV. Provider business mailing address

49650 CHERRY HILL RD SUITE 230
CANTON MI
48187-4849
US

V. Phone/Fax

Practice location:
  • Phone: 734-495-3725
  • Fax: 734-495-3734
Mailing address:
  • Phone: 734-495-3725
  • Fax: 734-495-3734

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number5501009528
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: