Provider Demographics
NPI:1275034233
Name:PITTSLEY, LORI FLYNN (PT)
Entity Type:Individual
Prefix:
First Name:LORI
Middle Name:FLYNN
Last Name:PITTSLEY
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4851 E PICKARD ST STE 2600
Mailing Address - Street 2:
Mailing Address - City:MT PLEASANT
Mailing Address - State:MI
Mailing Address - Zip Code:48858-2042
Mailing Address - Country:US
Mailing Address - Phone:989-775-1664
Mailing Address - Fax:989-775-1604
Practice Address - Street 1:4851 E PICKARD ST STE 2600
Practice Address - Street 2:
Practice Address - City:MT PLEASANT
Practice Address - State:MI
Practice Address - Zip Code:48858-2042
Practice Address - Country:US
Practice Address - Phone:989-775-1664
Practice Address - Fax:989-775-1604
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-26
Last Update Date:2018-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501002492225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1023097771Medicaid