Basic Information
| Provider Information | |||||||||
| NPI: | 1396807715 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WEBSTER | ||||||||
| FirstName: | LORI | ||||||||
| MiddleName: | JOANNE | ||||||||
| NamePrefix: | MS. | ||||||||
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| Credential: | MPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 804 SERVICE ROAD | ||||||||
| Address2: | ROOM A114 | ||||||||
| City: | EAST LANSING | ||||||||
| State: | MI | ||||||||
| PostalCode: | 488247038 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5173557648 | ||||||||
| FaxNumber: | 5174321319 | ||||||||
| Practice Location | |||||||||
| Address1: | 804 SERVICE ROAD | ||||||||
| Address2: | ROOM A114 | ||||||||
| City: | EAST LANSING | ||||||||
| State: | MI | ||||||||
| PostalCode: | 488247038 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5173557648 | ||||||||
| FaxNumber: | 5174321319 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/14/2006 | ||||||||
| LastUpdateDate: | 02/22/2013 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 5501009559 | MI | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 1396807715 | 05 | MI | MEDICAID |