Provider Demographics
NPI:1942701735
Name:WIRICK, DEANNA RENEE (MPT)
Entity Type:Individual
Prefix:MRS
First Name:DEANNA
Middle Name:RENEE
Last Name:WIRICK
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:MS
Other - First Name:DEANNA
Other - Middle Name:RENEE
Other - Last Name:LUCAS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:22019 NORMANDY AVE
Mailing Address - Street 2:
Mailing Address - City:EASTPOINTE
Mailing Address - State:MI
Mailing Address - Zip Code:48021-2511
Mailing Address - Country:US
Mailing Address - Phone:586-776-3728
Mailing Address - Fax:
Practice Address - Street 1:20952 E 12 MILE RD STE 110
Practice Address - Street 2:
Practice Address - City:SAINT CLAIR SHORES
Practice Address - State:MI
Practice Address - Zip Code:48081-3202
Practice Address - Country:US
Practice Address - Phone:586-498-3500
Practice Address - Fax:586-498-3510
Is Sole Proprietor?:No
Enumeration Date:2018-02-27
Last Update Date:2018-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI55010101982251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIF228781OtherBCBSM