Provider Demographics
NPI:1396417440
Name:SCHODOWSKI, RUPA (MT)
Entity Type:Individual
Prefix:
First Name:RUPA
Middle Name:
Last Name:SCHODOWSKI
Suffix:
Gender:F
Credentials:MT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:51424 VAN DYKE AVE STE 27
Mailing Address - Street 2:
Mailing Address - City:SHELBY TWP
Mailing Address - State:MI
Mailing Address - Zip Code:48316-4409
Mailing Address - Country:US
Mailing Address - Phone:586-258-6841
Mailing Address - Fax:
Practice Address - Street 1:51424 VAN DYKE AVE STE 27
Practice Address - Street 2:
Practice Address - City:SHELBY TWP
Practice Address - State:MI
Practice Address - Zip Code:48316-4409
Practice Address - Country:US
Practice Address - Phone:586-258-6841
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-28
Last Update Date:2022-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI7501000225225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1396417440Medicaid