Provider Demographics
NPI:1023334323
Name:KANE, CALLIE M (DPT)
Entity type:Individual
Prefix:MRS
First Name:CALLIE
Middle Name:M
Last Name:KANE
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:MISS
Other - First Name:CALLIE
Other - Middle Name:M
Other - Last Name:MANDEVILLE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DPT
Mailing Address - Street 1:26850 PROVIDENCE PKWY
Mailing Address - Street 2:STE 365
Mailing Address - City:NOVI
Mailing Address - State:MI
Mailing Address - Zip Code:48374-1262
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:33566 W 8 MILE RD
Practice Address - Street 2:STE A
Practice Address - City:FARMINGTON HILLS
Practice Address - State:MI
Practice Address - Zip Code:48335-5271
Practice Address - Country:US
Practice Address - Phone:248-478-7330
Practice Address - Fax:248-478-4352
Is Sole Proprietor?:No
Enumeration Date:2010-04-12
Last Update Date:2021-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501015073225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIMI6211074Medicare PIN