Provider Demographics
NPI:1730308115
Name:MOMENTUM REHABILITATION SERVICES, INC.
Entity Type:Organization
Organization Name:MOMENTUM REHABILITATION SERVICES, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:TERRY
Authorized Official - Middle Name:L
Authorized Official - Last Name:BRACISZEWSKI
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:734-320-2497
Mailing Address - Street 1:8838 HENDRICKS DR
Mailing Address - Street 2:
Mailing Address - City:BRIGHTON
Mailing Address - State:MI
Mailing Address - Zip Code:48116-9111
Mailing Address - Country:US
Mailing Address - Phone:734-320-2497
Mailing Address - Fax:810-231-0771
Practice Address - Street 1:7926 ANN ARBOR ST
Practice Address - Street 2:
Practice Address - City:DEXTER
Practice Address - State:MI
Practice Address - Zip Code:48130-1344
Practice Address - Country:US
Practice Address - Phone:734-320-2497
Practice Address - Fax:810-231-0771
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-24
Last Update Date:2014-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301006431103G00000X, 103T00000X, 103TB0200X, 103TC0700X, 103TH0100X, 103TP2701X, 103TR0400X, 103TH0100X, 103G00000X
225X00000X, 235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103G00000XBehavioral Health & Social Service ProvidersClinical NeuropsychologistGroup - Single Specialty
No103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty
No103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & BehavioralGroup - Single Specialty
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
No103TH0100XBehavioral Health & Social Service ProvidersPsychologistHealth ServiceGroup - Single Specialty
No103TP2701XBehavioral Health & Social Service ProvidersPsychologistGroup PsychotherapyGroup - Single Specialty
No103TR0400XBehavioral Health & Social Service ProvidersPsychologistRehabilitationGroup - Single Specialty
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Single Specialty
No235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH610093200OtherOWCS ACS
MI680H146930OtherBCBSM
OD74512OtherTRUST
MI680H146930OtherBCBSM
0N74040Medicare ID - Type Unspecified