Provider Demographics
NPI:1073593190
Name:IVANS, MICHELE R (MSPT)
Entity Type:Individual
Prefix:
First Name:MICHELE
Middle Name:R
Last Name:IVANS
Suffix:
Gender:F
Credentials:MSPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:942 ROSE AVE
Mailing Address - Street 2:
Mailing Address - City:BURLINGTON
Mailing Address - State:CO
Mailing Address - Zip Code:80807-1815
Mailing Address - Country:US
Mailing Address - Phone:719-346-6050
Mailing Address - Fax:719-346-5509
Practice Address - Street 1:2425 NW PRAIRIE VIEW RD
Practice Address - Street 2:
Practice Address - City:PLATTE CITY
Practice Address - State:MO
Practice Address - Zip Code:64079-7627
Practice Address - Country:US
Practice Address - Phone:816-858-3250
Practice Address - Fax:816-858-3253
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-17
Last Update Date:2020-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2005003641225100000X
KS11-03404225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO35214014OtherBLUE CROSS & BLUE SHIELD