Healthcare Provider Details

I. General information

NPI: 1356387450
Provider Name (Legal Business Name): TED ARTHUR LEZOTTE PHYSICAL THERAPIST
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/20/2006
Last Update Date: 09/18/2021
Certification Date: 03/22/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5500 AUTO CLUB DR
DEARBORN MI
48126-2779
US

IV. Provider business mailing address

39809 MAZUCHET DR
HARRISON TOWNSHIP MI
48045-1666
US

V. Phone/Fax

Practice location:
  • Phone: 313-982-8266
  • Fax:
Mailing address:
  • Phone: 734-347-4544
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number5501005446
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: