Provider Demographics
NPI:1265932024
Name:LINN, STACY DIETLIN (PT, DPT)
Entity type:Individual
Prefix:
First Name:STACY
Middle Name:DIETLIN
Last Name:LINN
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1555 E SOUTH BLVD
Mailing Address - Street 2:SUITE 120
Mailing Address - City:ROCHESTER HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48307
Mailing Address - Country:US
Mailing Address - Phone:248-267-5650
Mailing Address - Fax:
Practice Address - Street 1:1555 E. SOUTH BLVD
Practice Address - Street 2:SUITE 120
Practice Address - City:ROCHESTER HILLS
Practice Address - State:MI
Practice Address - Zip Code:48307
Practice Address - Country:US
Practice Address - Phone:248-268-5650
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-19
Last Update Date:2018-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501016156225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist