Healthcare Provider Details

I. General information

NPI: 1255667556
Provider Name (Legal Business Name): ABYSSINIA LOVE KNOT PHYSICAL THERAPY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/22/2009
Last Update Date: 09/09/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15340 SOUTHFIELD FREEWAY SUITE 1-A
DETROIT MI
48223
US

IV. Provider business mailing address

21700 GREENFIELD RD SUITE 215
OAK PARK MI
48237-2581
US

V. Phone/Fax

Practice location:
  • Phone: 313-646-6929
  • Fax: 313-646-6929
Mailing address:
  • Phone: 248-968-6899
  • Fax: 248-968-4443

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number
License Number State

VIII. Authorized Official

Name: MS. SHIRLEY A. DOUGLAS
Title or Position: ADMINISTRATOR APPROPRIATIONS CASE M
Credential: M.A.P.M, D.D.
Phone: 313-646-6929