Basic Information
| Provider Information | |||||||||
| NPI: | 1982904736 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MONETTE | ||||||||
| FirstName: | NICOLE | ||||||||
| MiddleName: | RENE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | DPT | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | BLAESSER | ||||||||
| OtherFirstName: | NICOLE | ||||||||
| OtherMiddleName: | RENE | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | DPT | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 33900 HARPER AVE | ||||||||
| Address2: | SUITE 104 | ||||||||
| City: | CLINTON TOWNSHIP | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480354258 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5864169100 | ||||||||
| FaxNumber: | 5864169103 | ||||||||
| Practice Location | |||||||||
| Address1: | 27652 FRANKLIN RD | ||||||||
| Address2: | |||||||||
| City: | SOUTHFIELD | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480348200 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2483598700 | ||||||||
| FaxNumber: | 2483598701 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/27/2010 | ||||||||
| LastUpdateDate: | 06/03/2015 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 5501015403 | MI | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 650F39531 | 01 | MI | BCBSM | OTHER |