Provider Demographics
NPI:1225315070
Name:BERHEN, MICHELLE CELESTE (PT MCSP)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:CELESTE
Last Name:BERHEN
Suffix:
Gender:F
Credentials:PT MCSP
Other - Prefix:
Other - First Name:MICHELLE
Other - Middle Name:CELESTE
Other - Last Name:THACKWRAY (BONNER)
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT MCSP
Mailing Address - Street 1:1058 N TAMIAMI TRAIL 108-280
Mailing Address - Street 2:
Mailing Address - City:SARASOTA
Mailing Address - State:FL
Mailing Address - Zip Code:34236
Mailing Address - Country:US
Mailing Address - Phone:727-678-4955
Mailing Address - Fax:
Practice Address - Street 1:1058 N TAMIAMI TRAIL 108-280
Practice Address - Street 2:
Practice Address - City:SARASOTA
Practice Address - State:FL
Practice Address - Zip Code:34236
Practice Address - Country:US
Practice Address - Phone:727-678-4955
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-11-08
Last Update Date:2016-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11188225100000X
FL225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist