Provider Demographics
NPI:1851465652
Name:STALLARD, LETRISHA COLLEEN (MSPT)
Entity Type:Individual
Prefix:MRS
First Name:LETRISHA
Middle Name:COLLEEN
Last Name:STALLARD
Suffix:
Gender:F
Credentials:MSPT
Other - Prefix:
Other - First Name:LETRISHA
Other - Middle Name:COLLEEN
Other - Last Name:RODGERS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MSPT
Mailing Address - Street 1:7302 WELLINGTON LANE
Mailing Address - Street 2:
Mailing Address - City:YPSILANTI
Mailing Address - State:MI
Mailing Address - Zip Code:48197
Mailing Address - Country:US
Mailing Address - Phone:734-484-1916
Mailing Address - Fax:734-484-1916
Practice Address - Street 1:5417 WHITTAKER RD
Practice Address - Street 2:
Practice Address - City:YPSILANTI
Practice Address - State:MI
Practice Address - Zip Code:48197-9751
Practice Address - Country:US
Practice Address - Phone:734-483-9200
Practice Address - Fax:734-483-9202
Is Sole Proprietor?:No
Enumeration Date:2006-11-20
Last Update Date:2009-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501009634225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist