Basic Information
| Provider Information | |||||||||
| NPI: | 1851465652 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | STALLARD | ||||||||
| FirstName: | LETRISHA | ||||||||
| MiddleName: | COLLEEN | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MSPT | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | RODGERS | ||||||||
| OtherFirstName: | LETRISHA | ||||||||
| OtherMiddleName: | COLLEEN | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | MSPT | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 7302 WELLINGTON LANE | ||||||||
| Address2: | |||||||||
| City: | YPSILANTI | ||||||||
| State: | MI | ||||||||
| PostalCode: | 48197 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7344841916 | ||||||||
| FaxNumber: | 7344841916 | ||||||||
| Practice Location | |||||||||
| Address1: | 5417 WHITTAKER RD | ||||||||
| Address2: | |||||||||
| City: | YPSILANTI | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481979751 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7344839200 | ||||||||
| FaxNumber: | 7344839202 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/20/2006 | ||||||||
| LastUpdateDate: | 06/16/2009 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 5501009634 | MI | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.