Provider Demographics
NPI:1003833716
Name:AT HOME PHYSICAL THERAPY
Entity Type:Organization
Organization Name:AT HOME PHYSICAL THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LAURA
Authorized Official - Middle Name:A
Authorized Official - Last Name:ELLIS
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:810-796-9102
Mailing Address - Street 1:5654 BELLE RIDGE CT
Mailing Address - Street 2:
Mailing Address - City:DRYDEN
Mailing Address - State:MI
Mailing Address - Zip Code:48428-9240
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5654 BELLE RIDGE CT
Practice Address - Street 2:
Practice Address - City:DRYDEN
Practice Address - State:MI
Practice Address - Zip Code:48428-9240
Practice Address - Country:US
Practice Address - Phone:810-796-9102
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-17
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501010803225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty