Provider Demographics
NPI:1083881320
Name:VINE, MICHELLE (PT)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:VINE
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1414 N TAYLOR DR
Mailing Address - Street 2:SUITE 105
Mailing Address - City:SHEBOYGAN
Mailing Address - State:WI
Mailing Address - Zip Code:53081-1988
Mailing Address - Country:US
Mailing Address - Phone:920-459-8475
Mailing Address - Fax:920-694-0437
Practice Address - Street 1:1414 N TAYLOR DR
Practice Address - Street 2:SUITE 105
Practice Address - City:SHEBOYGAN
Practice Address - State:WI
Practice Address - Zip Code:53081-1988
Practice Address - Country:US
Practice Address - Phone:920-459-8475
Practice Address - Fax:920-694-0437
Is Sole Proprietor?:No
Enumeration Date:2008-05-15
Last Update Date:2008-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4818024225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist