Provider Demographics
NPI:1871554899
Name:WALLIS, BENJAMIN JOHN (MSPT)
Entity type:Individual
Prefix:MR
First Name:BENJAMIN
Middle Name:JOHN
Last Name:WALLIS
Suffix:
Gender:M
Credentials:MSPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:39885 GRAND RIVER
Mailing Address - Street 2:STE 300
Mailing Address - City:NOVI
Mailing Address - State:MI
Mailing Address - Zip Code:48375
Mailing Address - Country:US
Mailing Address - Phone:248-615-0282
Mailing Address - Fax:248-615-0415
Practice Address - Street 1:39885 GRAND RIVER
Practice Address - Street 2:STE 300
Practice Address - City:NOVI
Practice Address - State:MI
Practice Address - Zip Code:48375
Practice Address - Country:US
Practice Address - Phone:248-615-0282
Practice Address - Fax:248-615-0415
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI1585173225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist