Provider Demographics
NPI:1407577661
Name:RYSIEWICZ, MIRANDA (PT, DPT)
Entity type:Individual
Prefix:
First Name:MIRANDA
Middle Name:
Last Name:RYSIEWICZ
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9368 N LILLEY RD
Mailing Address - Street 2:
Mailing Address - City:PLYMOUTH
Mailing Address - State:MI
Mailing Address - Zip Code:48170-4610
Mailing Address - Country:US
Mailing Address - Phone:586-359-2487
Mailing Address - Fax:586-359-2343
Practice Address - Street 1:30122 HARPER AVE
Practice Address - Street 2:
Practice Address - City:SAINT CLAIR SHORES
Practice Address - State:MI
Practice Address - Zip Code:48082-1642
Practice Address - Country:US
Practice Address - Phone:586-359-2487
Practice Address - Fax:586-359-2343
Is Sole Proprietor?:No
Enumeration Date:2022-09-07
Last Update Date:2025-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501301903225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist