Provider Demographics
NPI:1588981153
Name:WISE, KAMELIA LEANDRA (PT)
Entity type:Individual
Prefix:
First Name:KAMELIA
Middle Name:LEANDRA
Last Name:WISE
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:KAMELIA
Other - Middle Name:LEANDRA
Other - Last Name:SANDERS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:20251 STOTTER ST
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48234-3192
Mailing Address - Country:US
Mailing Address - Phone:202-904-7555
Mailing Address - Fax:
Practice Address - Street 1:24345 HARPER AVE
Practice Address - Street 2:
Practice Address - City:SAINT CLAIR SHORES
Practice Address - State:MI
Practice Address - Zip Code:48080-1285
Practice Address - Country:US
Practice Address - Phone:586-563-3300
Practice Address - Fax:586-563-3313
Is Sole Proprietor?:No
Enumeration Date:2010-04-22
Last Update Date:2010-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501015166225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist