Provider Demographics
NPI:1023331907
Name:EDWARDS, WENDYLIZA (PT)
Entity type:Individual
Prefix:
First Name:WENDYLIZA
Middle Name:
Last Name:EDWARDS
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5020 BORDEAUX DR
Mailing Address - Street 2:
Mailing Address - City:CLARKSTON
Mailing Address - State:MI
Mailing Address - Zip Code:48348-4905
Mailing Address - Country:US
Mailing Address - Phone:810-449-5678
Mailing Address - Fax:
Practice Address - Street 1:5020 BORDEAUX DR
Practice Address - Street 2:
Practice Address - City:CLARKSTON
Practice Address - State:MI
Practice Address - Zip Code:48348-4905
Practice Address - Country:US
Practice Address - Phone:810-449-5678
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-03-08
Last Update Date:2020-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501014112225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist