Provider Demographics
NPI:1821199589
Name:SOMMERFIELD, MARY LOU
Entity Type:Individual
Prefix:
First Name:MARY LOU
Middle Name:
Last Name:SOMMERFIELD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4304 PAGE AVE STE 100
Mailing Address - Street 2:
Mailing Address - City:MICHIGAN CENTER
Mailing Address - State:MI
Mailing Address - Zip Code:49254-1078
Mailing Address - Country:US
Mailing Address - Phone:517-205-7586
Mailing Address - Fax:517-205-0110
Practice Address - Street 1:4304 PAGE AVE STE 100
Practice Address - Street 2:
Practice Address - City:MICHIGAN CENTER
Practice Address - State:MI
Practice Address - Zip Code:49254
Practice Address - Country:US
Practice Address - Phone:517-205-7586
Practice Address - Fax:517-205-0110
Is Sole Proprietor?:No
Enumeration Date:2006-09-26
Last Update Date:2018-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501001496225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist