Provider Demographics
NPI:1497011746
Name:DANIELS, RICHARD JOHN (PTA)
Entity Type:Individual
Prefix:MR
First Name:RICHARD
Middle Name:JOHN
Last Name:DANIELS
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1538 MORRIS AVE
Mailing Address - Street 2:
Mailing Address - City:LINCOLN PARK
Mailing Address - State:MI
Mailing Address - Zip Code:48146-1545
Mailing Address - Country:US
Mailing Address - Phone:313-386-6725
Mailing Address - Fax:
Practice Address - Street 1:1538 MORRIS
Practice Address - Street 2:
Practice Address - City:LINCOLN PARK
Practice Address - State:MI
Practice Address - Zip Code:48146
Practice Address - Country:US
Practice Address - Phone:313-386-6725
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-04-11
Last Update Date:2012-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5502000369225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant