Provider Demographics
NPI:1457809196
Name:LACLAIR, THOMAS (DPT, CSCS)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:
Last Name:LACLAIR
Suffix:
Gender:M
Credentials:DPT, CSCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1161 E CLARK RD
Mailing Address - Street 2:156
Mailing Address - City:DEWITT
Mailing Address - State:MI
Mailing Address - Zip Code:48820-7930
Mailing Address - Country:US
Mailing Address - Phone:810-441-2185
Mailing Address - Fax:
Practice Address - Street 1:1161 E CLARK RD
Practice Address - Street 2:156
Practice Address - City:DEWITT
Practice Address - State:MI
Practice Address - Zip Code:48820-7930
Practice Address - Country:US
Practice Address - Phone:517-668-0000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-09-12
Last Update Date:2016-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501017916225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist