MEDICARE: FASTBACK PHYSICAL THERAPY LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor
2	225100000X	Physical Therapist

General Provider Information

NPI Number	:	1104393982
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FASTBACK PHYSICAL THERAPY LLC

Provider Business Mailing Address
First Line	:	1773 STAR BATT DR
Second Line	:
City	:	ROCHESTER HILLS
State	:	MI
Zip	:	48309-3708
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	3333 S SUNNYSLOPE RD STE 103B
Second Line	:
City	:	NEW BERLIN
State	:	WI
Zip	:	53151-4504
Country	:	US
Telephone Number	:	262-853-8452
Fax Number	:

Authorized Official
Title or Position	:	CREDENTIALING SPECIALIST
Name	:	MICHELE WENINGER
Credential	:
Telephone Number	:	248-601-9207

Provider Enumeration Date	:	10/30/2018
Last Update Date	:	08/06/2024

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