=====================================================
General NPI Number Information
=====================================================
NPI Number | 1245844703
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MOVEMENT PHYSICAL AND OCCUPATIONAL THERAPY LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/02/2020
-----------------------------------------------------
Last Update Date | 12/28/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 14700 KING RD STE B
-----------------------------------------------------
City | RIVERVIEW
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48193-7909
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 586-531-5825
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 14700 KING RD STE B
-----------------------------------------------------
City | RIVERVIEW
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48193-7909
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 586-531-5825
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PROVIDER/PARTNER
-----------------------------------------------------
Name | JUSTIN STREEFKERK
-----------------------------------------------------
Credential | DPT
-----------------------------------------------------
Telephone | 586-531-5825
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 225X00000X
-----------------------------------------------------
Taxonomy Name | Occupational Therapist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------