Provider Demographics
NPI:1033458765
Name:MASSINGALE, MICHELLE LYNN (PT)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:LYNN
Last Name:MASSINGALE
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:SHELLY
Other - Middle Name:LYNN
Other - Last Name:MASSINGALE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PT
Mailing Address - Street 1:1320 N 10TH ST STE B
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85006-2710
Mailing Address - Country:US
Mailing Address - Phone:602-839-7285
Mailing Address - Fax:602-839-7272
Practice Address - Street 1:1320 N 10TH ST STE B
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85006-2710
Practice Address - Country:US
Practice Address - Phone:602-839-7285
Practice Address - Fax:602-839-7272
Is Sole Proprietor?:No
Enumeration Date:2013-01-31
Last Update Date:2013-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ3764225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ807837Medicaid
AZZ157563Medicare PIN