Provider Demographics
NPI:1063817104
Name:ROTHGEB, MICHALE DIANE (PTA)
Entity Type:Individual
Prefix:MRS
First Name:MICHALE
Middle Name:DIANE
Last Name:ROTHGEB
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:MS
Other - First Name:MICHOLE
Other - Middle Name:DIANE
Other - Last Name:RITENOUR
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PTA
Mailing Address - Street 1:11109 PARKVIEW PLAZA DR
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46845
Mailing Address - Country:US
Mailing Address - Phone:260-373-3202
Mailing Address - Fax:260-373-4548
Practice Address - Street 1:2200 RANDOLLIA DR
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46805
Practice Address - Country:US
Practice Address - Phone:260-373-3202
Practice Address - Fax:260-373-4548
Is Sole Proprietor?:No
Enumeration Date:2014-10-31
Last Update Date:2014-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN06003715A225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant