Healthcare Provider Details

I. General information

NPI: 1528918331
Provider Name (Legal Business Name): PEACE PHYSICAL THERAPY PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/31/2026
Last Update Date: 02/17/2026
Certification Date: 02/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

995 N PONTIAC TRL UNIT 144
WALLED LAKE MI
48390-7005
US

IV. Provider business mailing address

995 N PONTIAC TRL UNIT 144
WALLED LAKE MI
48390-7005
US

V. Phone/Fax

Practice location:
  • Phone: 248-931-1517
  • Fax:
Mailing address:
  • Phone: 248-931-1517
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number
License Number State

VIII. Authorized Official

Name: DR. RYAN WATHA
Title or Position: PHYSICAL THERAPIST
Credential: DPT
Phone: 248-931-1517