Healthcare Provider Details

I. General information

NPI: 1053049510
Provider Name (Legal Business Name): SERAPHINA PROVENZANO DPT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/12/2022
Last Update Date: 08/10/2023
Certification Date: 08/10/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5500 AUTO CLUB DR
DEARBORN MI
48126-2779
US

IV. Provider business mailing address

1 FORD PL
DETROIT MI
48202-3450
US

V. Phone/Fax

Practice location:
  • Phone: 313-982-8266
  • Fax: 313-982-8098
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number5501301928
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: