Provider Demographics
NPI:1164574935
Name:WOZNIAK, LANCE THADDEUS (PT, DPT)
Entity Type:Individual
Prefix:
First Name:LANCE
Middle Name:THADDEUS
Last Name:WOZNIAK
Suffix:
Gender:M
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 772039
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48277
Mailing Address - Country:US
Mailing Address - Phone:248-988-8085
Mailing Address - Fax:248-988-8565
Practice Address - Street 1:24255 W 13 MILE RD STE 100
Practice Address - Street 2:
Practice Address - City:BINGHAM FARMS
Practice Address - State:MI
Practice Address - Zip Code:48025-4345
Practice Address - Country:US
Practice Address - Phone:248-988-8085
Practice Address - Fax:248-988-8565
Is Sole Proprietor?:No
Enumeration Date:2007-01-18
Last Update Date:2017-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501011569225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1164574935Medicaid
MI1164574935Medicaid