Healthcare Provider Details

I. General information

NPI: 1548595598
Provider Name (Legal Business Name): PROF. LOLITA MARIA MALISKEY
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/08/2009
Last Update Date: 10/08/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

24725 W 12 MILE RD SUITE 302
SOUTHFIELD MI
48034-1801
US

IV. Provider business mailing address

24725 W 12 MILE RD SUITE 302
SOUTHFIELD MI
48034-1801
US

V. Phone/Fax

Practice location:
  • Phone: 888-686-4300
  • Fax: 248-350-8919
Mailing address:
  • Phone: 888-686-4300
  • Fax: 248-350-8919

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number5501009638
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: