# FASTBACK PHYSICAL THERAPY LLC

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- **Entity:** Organization
- **Status:** Active
- **Organization subpart:** No

## Provider details

- **NPI number:** 1104393982
- **Authorized official:** MICHELE WENINGER (CREDENTIALING SPECIALIST)
- **Authorized official phone:** (248) 601-9207

## Contact information

- **Practice address:** 3333 S SUNNYSLOPE RD STE 103B, NEW BERLIN, WI 53151-4504
- **Practice address phone:** (262) 853-8452
- **Mailing address:** 1773 STAR BATT DR, ROCHESTER HILLS, MI 48309-3708

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 101YM0800X | Mental Health Counselor | — | NULL | — |
| 101YM0800X | Mental Health Counselor | — | — | — |
| 225100000X | Physical Therapist | — | NULL | Yes |
| 225100000X | Physical Therapist | — | — | Yes |

## Other

- **Enumeration date:** 10/30/2018
- **Last updated:** 08/06/2024