Provider Demographics
NPI:1871994046
Name:TISDALL, RYAN (DPT)
Entity type:Individual
Prefix:
First Name:RYAN
Middle Name:
Last Name:TISDALL
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:40440 GRAND RIVER AVE STE D
Mailing Address - Street 2:
Mailing Address - City:NOVI
Mailing Address - State:MI
Mailing Address - Zip Code:48375-2873
Mailing Address - Country:US
Mailing Address - Phone:248-957-9430
Mailing Address - Fax:248-436-4929
Practice Address - Street 1:40440 GRAND RIVER AVE STE D
Practice Address - Street 2:
Practice Address - City:NOVI
Practice Address - State:MI
Practice Address - Zip Code:48375-2873
Practice Address - Country:US
Practice Address - Phone:248-957-9430
Practice Address - Fax:248-436-4929
Is Sole Proprietor?:No
Enumeration Date:2014-09-08
Last Update Date:2020-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501016891225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist