Provider Demographics
NPI:1831543164
Name:RAINES, PEGGY LEE
Entity type:Individual
Prefix:
First Name:PEGGY
Middle Name:LEE
Last Name:RAINES
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:105 8 MILE RD
Mailing Address - Street 2:
Mailing Address - City:REMUS
Mailing Address - State:MI
Mailing Address - Zip Code:49340-9754
Mailing Address - Country:US
Mailing Address - Phone:989-824-8146
Mailing Address - Fax:
Practice Address - Street 1:1524 PORTABELLA TRL
Practice Address - Street 2:
Practice Address - City:MT PLEASANT
Practice Address - State:MI
Practice Address - Zip Code:48858-4006
Practice Address - Country:US
Practice Address - Phone:989-772-2967
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-22
Last Update Date:2016-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5502004766225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant