Provider Demographics
NPI:1538817309
Name:ANGELOSANTO, RYAN JAMES (PTA)
Entity type:Individual
Prefix:
First Name:RYAN
Middle Name:JAMES
Last Name:ANGELOSANTO
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:43443 GRAND RIVER AVE STE 200
Mailing Address - Street 2:
Mailing Address - City:NOVI
Mailing Address - State:MI
Mailing Address - Zip Code:48375-1106
Mailing Address - Country:US
Mailing Address - Phone:248-305-9200
Mailing Address - Fax:248-305-9330
Practice Address - Street 1:43443 GRAND RIVER AVE STE 200
Practice Address - Street 2:
Practice Address - City:NOVI
Practice Address - State:MI
Practice Address - Zip Code:48375-1106
Practice Address - Country:US
Practice Address - Phone:248-305-9200
Practice Address - Fax:248-305-9330
Is Sole Proprietor?:No
Enumeration Date:2022-03-11
Last Update Date:2022-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5502005470225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant