Provider Demographics
NPI:1821131228
Name:FAKULT, RYAN (DPT)
Entity Type:Individual
Prefix:MR
First Name:RYAN
Middle Name:
Last Name:FAKULT
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:33900 HARPER AVE
Mailing Address - Street 2:SUITE 104
Mailing Address - City:CLINTON TOWNSHIP
Mailing Address - State:MI
Mailing Address - Zip Code:48035-4258
Mailing Address - Country:US
Mailing Address - Phone:586-350-2644
Mailing Address - Fax:586-541-3735
Practice Address - Street 1:18161 W 13 MILE RD STE A1
Practice Address - Street 2:
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48076-1113
Practice Address - Country:US
Practice Address - Phone:248-633-2640
Practice Address - Fax:248-633-2643
Is Sole Proprietor?:No
Enumeration Date:2007-02-15
Last Update Date:2024-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI0704026672255A2300X
MI5501016650225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer