Healthcare Provider Details

I. General information

NPI: 1295084416
Provider Name (Legal Business Name): FRAN ROTH DPT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/04/2012
Last Update Date: 09/04/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2636 S. MILFORD RD.
HIGHLAND MI
48357
US

IV. Provider business mailing address

30655 OLDSTREAM ST.
SOUTHFIELD MI
48076
US

V. Phone/Fax

Practice location:
  • Phone: 248-684-9610
  • Fax:
Mailing address:
  • Phone: 248-642-5145
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2251P0200X
TaxonomyPediatric Physical Therapist
License Number5501001589
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: