Provider Demographics
NPI:1902052574
Name:ROSS, BRENDA ANNE (MPT)
Entity Type:Individual
Prefix:MRS
First Name:BRENDA
Middle Name:ANNE
Last Name:ROSS
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:29100 GATEWAY BLVD
Mailing Address - Street 2:SUITE 400
Mailing Address - City:FLAT ROCK
Mailing Address - State:MI
Mailing Address - Zip Code:48134-2764
Mailing Address - Country:US
Mailing Address - Phone:734-379-7900
Mailing Address - Fax:
Practice Address - Street 1:29100 GATEWAY BLVD
Practice Address - Street 2:SUITE 400
Practice Address - City:FLAT ROCK
Practice Address - State:MI
Practice Address - Zip Code:48134-2764
Practice Address - Country:US
Practice Address - Phone:734-379-7900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-08-14
Last Update Date:2008-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501013896225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI236836OtherMEDICARE PROVIDER