Provider Demographics
NPI:1225315849
Name:RUSSELL, MICHELLE JEAN (DPT)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:JEAN
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5538 N SHASTA DR
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:WI
Mailing Address - Zip Code:53209-4925
Mailing Address - Country:US
Mailing Address - Phone:920-540-8626
Mailing Address - Fax:
Practice Address - Street 1:5538 N SHASTA DR
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:WI
Practice Address - Zip Code:53209-4925
Practice Address - Country:US
Practice Address - Phone:920-540-8626
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-10
Last Update Date:2014-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI11860-24225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist