Provider Demographics
NPI:1184355372
Name:LIEDERBACH, STEPHANIE PAIGE (DPT)
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:PAIGE
Last Name:LIEDERBACH
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14 N WALLACE BLVD
Mailing Address - Street 2:
Mailing Address - City:YPSILANTI
Mailing Address - State:MI
Mailing Address - Zip Code:48197-4664
Mailing Address - Country:US
Mailing Address - Phone:734-474-2629
Mailing Address - Fax:
Practice Address - Street 1:22180 PONTIAC TRL STE E
Practice Address - Street 2:
Practice Address - City:SOUTH LYON
Practice Address - State:MI
Practice Address - Zip Code:48178-9097
Practice Address - Country:US
Practice Address - Phone:248-446-0155
Practice Address - Fax:248-446-0177
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-20
Last Update Date:2022-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI55010171922251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic