Provider Demographics
NPI:1770605842
Name:PALMER, AUDREY JEAN (MPT)
Entity type:Individual
Prefix:
First Name:AUDREY
Middle Name:JEAN
Last Name:PALMER
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:45478 RATHMORE DR
Mailing Address - Street 2:
Mailing Address - City:MACOMB
Mailing Address - State:MI
Mailing Address - Zip Code:48044-6324
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:17900 23 MILE RD
Practice Address - Street 2:SUITE 401
Practice Address - City:MACOMB
Practice Address - State:MI
Practice Address - Zip Code:48044-1161
Practice Address - Country:US
Practice Address - Phone:586-868-9040
Practice Address - Fax:586-868-9013
Is Sole Proprietor?:No
Enumeration Date:2007-04-06
Last Update Date:2014-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501011741225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist