Provider Demographics
NPI:1548848609
Name:JAMES, DESIREE KAY (PTA)
Entity type:Individual
Prefix:
First Name:DESIREE
Middle Name:KAY
Last Name:JAMES
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:DESIREE
Other - Middle Name:KAY
Other - Last Name:LUNDY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PTA
Mailing Address - Street 1:28495 S DR N
Mailing Address - Street 2:
Mailing Address - City:SPRINGPORT
Mailing Address - State:MI
Mailing Address - Zip Code:49284-9447
Mailing Address - Country:US
Mailing Address - Phone:517-581-9329
Mailing Address - Fax:
Practice Address - Street 1:1201 E MICHIGAN AVE
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MI
Practice Address - Zip Code:49201-1852
Practice Address - Country:US
Practice Address - Phone:517-205-7633
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-31
Last Update Date:2021-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5502005305225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant