Provider Demographics
NPI:1558828798
Name:MARQUARDT, LORI LYNN
Entity Type:Individual
Prefix:
First Name:LORI
Middle Name:LYNN
Last Name:MARQUARDT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:415 QUAY ST
Mailing Address - Street 2:
Mailing Address - City:PORT HURON
Mailing Address - State:MI
Mailing Address - Zip Code:48060-3829
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:415 QUAY ST
Practice Address - Street 2:
Practice Address - City:PORT HURON
Practice Address - State:MI
Practice Address - Zip Code:48060-3829
Practice Address - Country:US
Practice Address - Phone:810-966-3480
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-25
Last Update Date:2019-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5502001558225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy AssistantGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1871542100Medicaid