Provider Demographics
NPI:1518206283
Name:DERY, LYNETTE MARIE (PT)
Entity Type:Individual
Prefix:MRS
First Name:LYNETTE
Middle Name:MARIE
Last Name:DERY
Suffix:
Gender:F
Credentials:PT
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Mailing Address - Street 1:625 KENMOOR AVE SE STE 100
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49546-2395
Mailing Address - Country:US
Mailing Address - Phone:616-483-3780
Mailing Address - Fax:616-356-5001
Practice Address - Street 1:4800 MEXICO RD STE 104
Practice Address - Street 2:
Practice Address - City:SAINT PETERS
Practice Address - State:MO
Practice Address - Zip Code:63376-1666
Practice Address - Country:US
Practice Address - Phone:636-939-9540
Practice Address - Fax:636-939-9886
Is Sole Proprietor?:No
Enumeration Date:2013-01-31
Last Update Date:2023-07-05
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
WI3614-0242251X0800X
FL00057672251X0800X
MA198572251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic