Provider Demographics
NPI:1114933587
Name:DOUGLAS, MICHELLE (PT)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:DOUGLAS
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:CATHERINE
Other - Middle Name:
Other - Last Name:DOUGLAS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:676 BATTLEFIELD BLVD N STE C
Mailing Address - Street 2:
Mailing Address - City:CHESAPEAKE
Mailing Address - State:VA
Mailing Address - Zip Code:23320-0306
Mailing Address - Country:US
Mailing Address - Phone:757-436-2695
Mailing Address - Fax:757-436-2697
Practice Address - Street 1:676 BATTLEFIELD BLVD N STE C
Practice Address - Street 2:
Practice Address - City:CHESAPEAKE
Practice Address - State:VA
Practice Address - Zip Code:23320-0306
Practice Address - Country:US
Practice Address - Phone:757-436-2695
Practice Address - Fax:757-436-2697
Is Sole Proprietor?:No
Enumeration Date:2006-07-31
Last Update Date:2020-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2305005425225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
00X158H01Medicare ID - Type Unspecified