Provider Demographics
NPI:1720614688
Name:TULETT, MICHAEL J (AT)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:J
Last Name:TULETT
Suffix:
Gender:M
Credentials:AT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24200 SUMPTER RD
Mailing Address - Street 2:
Mailing Address - City:BELLEVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:48111-9680
Mailing Address - Country:US
Mailing Address - Phone:734-985-8955
Mailing Address - Fax:
Practice Address - Street 1:281 ENTERPRISE CT
Practice Address - Street 2:
Practice Address - City:BLOOMFIELD HILLS
Practice Address - State:MI
Practice Address - Zip Code:48302-0309
Practice Address - Country:US
Practice Address - Phone:248-322-5280
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-22
Last Update Date:2020-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI26010002932255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2601000293OtherSTATE OF MICHIGAN LICENSE