Basic Information
| Provider Information | |||||||||
| NPI: | 1730363573 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CRAWL WALK JUMP RUN THERAPY CLINIC LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 43239 SCHOENHERR RD | ||||||||
| Address2: | |||||||||
| City: | STERLING HEIGHTS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 483131957 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5863232957 | ||||||||
| FaxNumber: | 5863230022 | ||||||||
| Practice Location | |||||||||
| Address1: | 43239 SCHOENHERR RD | ||||||||
| Address2: | |||||||||
| City: | STERLING HEIGHTS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 483131957 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5863232957 | ||||||||
| FaxNumber: | 5863230022 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/27/2007 | ||||||||
| LastUpdateDate: | 02/02/2012 | ||||||||
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| AuthorizedOfficialLastName: | SERAFIMOVSKI | ||||||||
| AuthorizedOfficialFirstName: | STEPHANIE | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 5863232957 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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| AuthorizedOfficialCredential: | MPT | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225X00000X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | 225100000X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 104942376 | 05 | MI | MEDICAID |