Provider Demographics
NPI:1508281072
Name:STATHAKIOS, ANGELIQUE MARIE
Entity Type:Individual
Prefix:MRS
First Name:ANGELIQUE
Middle Name:MARIE
Last Name:STATHAKIOS
Suffix:
Gender:F
Credentials:
Other - Prefix:MISS
Other - First Name:ANGIE
Other - Middle Name:
Other - Last Name:PALLIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1731 LINCOLNSHIRE DR
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48309-4528
Mailing Address - Country:US
Mailing Address - Phone:586-531-1041
Mailing Address - Fax:248-340-1878
Practice Address - Street 1:1731 LINCOLNSHIRE DR
Practice Address - Street 2:
Practice Address - City:ROCHESTER HILLS
Practice Address - State:MI
Practice Address - Zip Code:48309-4528
Practice Address - Country:US
Practice Address - Phone:586-531-1041
Practice Address - Fax:248-340-1878
Is Sole Proprietor?:No
Enumeration Date:2014-02-20
Last Update Date:2014-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501005429225100000X, 2251P0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics