Provider Demographics
NPI:1578785242
Name:KNICKERBOCKER, PAMELA SUE (PT)
Entity Type:Individual
Prefix:
First Name:PAMELA
Middle Name:SUE
Last Name:KNICKERBOCKER
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:8456 PONTIAC TRL
Mailing Address - Street 2:
Mailing Address - City:SOUTH LYON
Mailing Address - State:MI
Mailing Address - Zip Code:48178-7018
Mailing Address - Country:US
Mailing Address - Phone:734-763-4797
Mailing Address - Fax:734-763-3715
Practice Address - Street 1:325 E EISENHOWER PKWY
Practice Address - Street 2:2ND FLOOR
Practice Address - City:ANN ARBOR
Practice Address - State:MI
Practice Address - Zip Code:48108-3364
Practice Address - Country:US
Practice Address - Phone:734-763-4797
Practice Address - Fax:734-763-3715
Is Sole Proprietor?:No
Enumeration Date:2007-05-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI55010030102251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic