Provider Demographics
NPI:1033670310
Name:MIRES, MICHELLE (PT, DPT)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:MIRES
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:MICHELLE
Other - Middle Name:
Other - Last Name:ERNSDORFF
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 5299
Mailing Address - Street 2:MS: 820-5-PCO
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98415-0299
Mailing Address - Country:US
Mailing Address - Phone:253-459-8009
Mailing Address - Fax:
Practice Address - Street 1:17307 SE 272ND ST STE 142
Practice Address - Street 2:
Practice Address - City:COVINGTON
Practice Address - State:WA
Practice Address - Zip Code:98042-5330
Practice Address - Country:US
Practice Address - Phone:253-243-7528
Practice Address - Fax:253-243-7527
Is Sole Proprietor?:No
Enumeration Date:2019-03-28
Last Update Date:2023-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA60912130225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist