{
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"NameSuffix": null,
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"FirstLineMailingAddress": "455 E GRAND RIVER AVE",
"SecondLineMailingAddress": "SUITE 102",
"MailingAddressCityName": "BRIGHTON",
"MailingAddressStateName": "MI",
"MailingAddressPostalCode": "48116-1551",
"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "810-360-0806",
"MailingAddressFaxNumber": "810-360-0327",
"FirstLinePracticeLocationAddress": "455 E GRAND RIVER AVE",
"SecondLinePracticeLocationAddress": "SUITE 102",
"PracticeLocationAddressCityName": "BRIGHTON",
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"PracticeLocationAddressCountryCode": "US",
"PracticeLocationAddressTelephoneNumber": "810-360-0806",
"PracticeLocationAddressFaxNumber": "810-360-0327",
"EnumerationDate": "02/26/2016",
"LastUpdateDate": "06/09/2016",
"NPIDeactivationReasonCode": null,
"NPIDeactivationReason": null,
"NPIDeactivationDate": null,
"NPIReactivationDate": null,
"GenderCode": null,
"Gender": null,
"AuthorizedOfficialLastName": "GALLEGOS",
"AuthorizedOfficialFirstName": "AMY",
"AuthorizedOfficialMiddleName": "ELIZABETH",
"AuthorizedOfficialTitle": "OWNER/PHYSICAL THERAPIST",
"AuthorizedOfficialNamePrefix": null,
"AuthorizedOfficialNameSuffix": null,
"AuthorizedOfficialCredential": "DPT",
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"Taxonomies": {
"Taxonomy": {
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"TaxonomyName": "Physical Therapist",
"LicenseNumber": "5501011484",
"LicenseNumberStateCode": "MI",
"PrimaryTaxonomySwitch": "Y"
}
},
"HealthcareProviderTaxonomyGroups": {
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"HealthcareProviderTaxonomyGroupName": "193400000X SINGLE SPECIALTY GROUP",
"HealthcareProviderTaxonomyGroupDescription": "Single Specialty Group - A business group of one or more individual practitioners, all of who practice with the same area of specialization."
}
}
}
}