Provider Demographics
NPI:1710653332
Name:LECLAIR, SOPHIA (DPT)
Entity Type:Individual
Prefix:
First Name:SOPHIA
Middle Name:
Last Name:LECLAIR
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:555 W 14 MILE RD STE B2
Mailing Address - Street 2:
Mailing Address - City:CLAWSON
Mailing Address - State:MI
Mailing Address - Zip Code:48017-3100
Mailing Address - Country:US
Mailing Address - Phone:248-733-3885
Mailing Address - Fax:248-566-0098
Practice Address - Street 1:555 W 14 MILE RD STE B2
Practice Address - Street 2:
Practice Address - City:CLAWSON
Practice Address - State:MI
Practice Address - Zip Code:48017-3100
Practice Address - Country:US
Practice Address - Phone:248-733-3885
Practice Address - Fax:248-566-0098
Is Sole Proprietor?:No
Enumeration Date:2021-08-23
Last Update Date:2024-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1710653332Medicaid