Provider Demographics
NPI:1588809354
Name:TUSTIN, LAURA KAZNECKI (DPT)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:KAZNECKI
Last Name:TUSTIN
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:LAURA
Other - Middle Name:
Other - Last Name:KAZNECKI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:600 OAKMONT LN STE 600C
Mailing Address - Street 2:
Mailing Address - City:WESTMONT
Mailing Address - State:IL
Mailing Address - Zip Code:60559-5548
Mailing Address - Country:US
Mailing Address - Phone:630-575-6200
Mailing Address - Fax:630-928-5080
Practice Address - Street 1:43443 GRAND RIVER AVE
Practice Address - Street 2:STE 200
Practice Address - City:NOVI
Practice Address - State:MI
Practice Address - Zip Code:48375-1106
Practice Address - Country:US
Practice Address - Phone:248-305-9200
Practice Address - Fax:248-305-9330
Is Sole Proprietor?:No
Enumeration Date:2008-12-09
Last Update Date:2018-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO9999225100000X
MI5501013212225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist