Healthcare Provider Details

I. General information

NPI: 1982674040
Provider Name (Legal Business Name): GREAT LAKES ORTHOPEDIC PHYSICAL THERAPY, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/23/2006
Last Update Date: 02/15/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

38300 VAN DYKE AVE SUITE 101
STERLING HEIGHTS MI
48312-1123
US

IV. Provider business mailing address

38300 VAN DYKE AVE SUITE 101
STERLING HEIGHTS MI
48312-1123
US

V. Phone/Fax

Practice location:
  • Phone: 586-977-5700
  • Fax: 586-977-5704
Mailing address:
  • Phone: 586-977-5700
  • Fax: 586-977-5704

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code2251E1200X
TaxonomyErgonomics Physical Therapist
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code2251G0304X
TaxonomyGeriatric Physical Therapist
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code2251H1200X
TaxonomyHand Physical Therapist
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code2251N0400X
TaxonomyNeurology Physical Therapist
License Number
License Number State
# 7
Primary TaxonomyN
Taxonomy Code2251P0200X
TaxonomyPediatric Physical Therapist
License Number
License Number State
# 8
Primary TaxonomyN
Taxonomy Code2251S0007X
TaxonomySports Physical Therapist
License Number
License Number State
# 9
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number
License Number State
# 10
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number
License Number State
# 11
Primary TaxonomyY
Taxonomy Code2251X0800X
TaxonomyOrthopedic Physical Therapist
License Number
License Number State

VIII. Authorized Official

Name: DR. PIOTR KLUBA
Title or Position: PRESIDENT
Credential: P.T.
Phone: 586-977-5700