Healthcare Provider Details

I. General information

NPI: 1093445900
Provider Name (Legal Business Name): LUMEN PEDIATRIC THERAPY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/14/2022
Last Update Date: 04/27/2026
Certification Date: 04/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

26210 HARPER AVE STE 200
SAINT CLAIR SHORES MI
48081-2203
US

IV. Provider business mailing address

26210 HARPER AVE STE 200
SAINT CLAIR SHORES MI
48081-2203
US

V. Phone/Fax

Practice location:
  • Phone: 888-485-8636
  • Fax: 586-218-3367
Mailing address:
  • Phone: 888-485-8636
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number
License Number State

VIII. Authorized Official

Name: WAYNE KVINTUS
Title or Position: CHIEF EXECUTIVE OFFICER
Credential:
Phone: 313-550-6258