Provider Demographics
NPI:1043484165
Name:TAVALIERI, DONNA (PT)
Entity type:Individual
Prefix:
First Name:DONNA
Middle Name:
Last Name:TAVALIERI
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23256 ROBERT JOHN ST
Mailing Address - Street 2:
Mailing Address - City:SAINT CLAIR SHORES
Mailing Address - State:MI
Mailing Address - Zip Code:48080-2609
Mailing Address - Country:US
Mailing Address - Phone:586-445-8200
Mailing Address - Fax:586-445-8201
Practice Address - Street 1:19505 E 8 MILE RD
Practice Address - Street 2:
Practice Address - City:SAINT CLAIR SHORES
Practice Address - State:MI
Practice Address - Zip Code:48080-1643
Practice Address - Country:US
Practice Address - Phone:586-445-8200
Practice Address - Fax:586-445-8201
Is Sole Proprietor?:No
Enumeration Date:2008-04-18
Last Update Date:2010-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI55010038142251P0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5501003814OtherSTATE LICENSE NUMBER