MEDICARE: LAURA JEAN WIDDOWS MPT

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	225100000X	Physical Therapist	5501011710	MI

General Provider Information

NPI Number	:	1245317361
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LAURA JEAN WIDDOWS MPT

Provider Business Mailing Address
First Line	:	43902 WOODWARD AVE STE 120
Second Line	:
City	:	BLOOMFIELD HILLS
State	:	MI
Zip	:	48302-5021
Country	:	US
Telephone Number	:	248-338-7600
Fax Number	:	586-771-4993

Provider Business Practice Location Address
First Line	:	43902 WOODWARD AVE STE 120
Second Line	:
City	:	BLOOMFIELD HILLS
State	:	MI
Zip	:	48302-5021
Country	:	US
Telephone Number	:	248-338-7600
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/01/2006
Last Update Date	:	08/17/2023

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