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General NPI Number Information
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NPI Number | 1306902168
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Entity Type | Individual
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Provider Name | DAPHNE MATILDO P.T.
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Gender | Female
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Dates
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Enumeration Date | 12/28/2006
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Last Update Date | 07/08/2007
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Provider Practice Location Address
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Address Line | 12855 DIX TOLEDO RD
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City | SOUTHGATE
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State | MI
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Zip | 48195-1744
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Country | US
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Telephone | 734-283-2526
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Fax |
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Provider Business Mailing Address
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Address Line | 13200 VILLAGE PARK DR APT 1041
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City | SOUTHGATE
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State | MI
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Zip | 48195-2758
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Country | US
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Telephone | 219-741-2546
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225100000X
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Taxonomy Name | Physical Therapist
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License Number | 5501012453
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License Number State | MI
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