Healthcare Provider Details

I. General information

NPI: 1760885974
Provider Name (Legal Business Name): HENDRIKA LIETZ
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/01/2014
Last Update Date: 09/19/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

27622 5 MILE RD
LIVONIA MI
48154-3946
US

IV. Provider business mailing address

27622 5 MILE RD
LIVONIA MI
48154-3946
US

V. Phone/Fax

Practice location:
  • Phone: 734-452-2144
  • Fax: 734-452-2144
Mailing address:
  • Phone: 734-272-8698
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number5501003124
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code2251N0400X
TaxonomyNeurology Physical Therapist
License Number5501003124
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: