Provider Demographics
NPI:1376952853
Name:LAKE ISABELLA PHYSICAL THERAPY, LLC
Entity Type:Organization
Organization Name:LAKE ISABELLA PHYSICAL THERAPY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT, PT, DPT
Authorized Official - Prefix:DR
Authorized Official - First Name:SHANNON
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:DEXTER
Authorized Official - Suffix:
Authorized Official - Credentials:PT, DPT
Authorized Official - Phone:989-546-7490
Mailing Address - Street 1:50 N COLDWATER RD
Mailing Address - Street 2:SUITE D
Mailing Address - City:WEIDMAN
Mailing Address - State:MI
Mailing Address - Zip Code:48893-8845
Mailing Address - Country:US
Mailing Address - Phone:989-546-7490
Mailing Address - Fax:989-546-7298
Practice Address - Street 1:50 N COLDWATER RD
Practice Address - Street 2:SUITE D
Practice Address - City:WEIDMAN
Practice Address - State:MI
Practice Address - Zip Code:48893-8845
Practice Address - Country:US
Practice Address - Phone:989-546-7490
Practice Address - Fax:989-546-7298
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-08-08
Last Update Date:2014-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501014675225100000X
MI5502003378225200000X
MI5502001683225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy AssistantGroup - Single Specialty
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1376811729OtherPTAN MI5338
MIUNVLIPT2011Medicaid