Basic Information
| Provider Information | |||||||||
| NPI: | 1174860860 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DECKER | ||||||||
| FirstName: | KRISTEN | ||||||||
| MiddleName: | |||||||||
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| Credential: | D.P.T. | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | EVEY | ||||||||
| OtherFirstName: | KRISTEN | ||||||||
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| OtherCredential: | D.P.T. | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 17834 BEECHWOOD AVE | ||||||||
| Address2: | |||||||||
| City: | BEVERLY HILLS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480255528 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 26850 PROVIDENCE PKWY | ||||||||
| Address2: | SUITE 365 | ||||||||
| City: | NOVI | ||||||||
| State: | MI | ||||||||
| PostalCode: | 483741213 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2483803550 | ||||||||
| FaxNumber: | 2483801620 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/15/2013 | ||||||||
| LastUpdateDate: | 08/05/2013 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 5501016161 | MI | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.