Healthcare Provider Details

I. General information

NPI: 1184355372
Provider Name (Legal Business Name): STEPHANIE PAIGE LIEDERBACH DPT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/20/2022
Last Update Date: 06/20/2022
Certification Date: 06/20/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22180 PONTIAC TRL STE E
SOUTH LYON MI
48178-9097
US

IV. Provider business mailing address

14 N WALLACE BLVD
YPSILANTI MI
48197-4664
US

V. Phone/Fax

Practice location:
  • Phone: 248-446-0155
  • Fax: 248-446-0177
Mailing address:
  • Phone: 734-474-2629
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2251X0800X
TaxonomyOrthopedic Physical Therapist
License Number5501017192
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: