=====================================================
General NPI Number Information
=====================================================
NPI Number | 1255214573
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PHOENIX RESTORATIVE THERAPY PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/26/2025
-----------------------------------------------------
Last Update Date | 07/26/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5014 S STATE RD
-----------------------------------------------------
City | DAVISON
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48423-8753
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 734-210-1227
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1459 ROSEWOOD ST
-----------------------------------------------------
City | ANN ARBOR
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48104-6230
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGING PARTNER
-----------------------------------------------------
Name | SARAI KOSTER-STETSON
-----------------------------------------------------
Credential | LLMSW
-----------------------------------------------------
Telephone | 734-210-1227
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------