Provider Demographics
NPI:1730416470
Name:FEDESON, LORA CATHERINE (PT, CMT)
Entity type:Individual
Prefix:MRS
First Name:LORA
Middle Name:CATHERINE
Last Name:FEDESON
Suffix:
Gender:F
Credentials:PT, CMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30345 WICKLOW RD
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48334-4769
Mailing Address - Country:US
Mailing Address - Phone:248-471-4586
Mailing Address - Fax:
Practice Address - Street 1:1100 CORPORATE OFFICE DR
Practice Address - Street 2:SUITE 100
Practice Address - City:MILFORD
Practice Address - State:MI
Practice Address - Zip Code:48381-5001
Practice Address - Country:US
Practice Address - Phone:248-684-1107
Practice Address - Fax:248-684-1681
Is Sole Proprietor?:Yes
Enumeration Date:2009-11-16
Last Update Date:2009-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501004510225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist