Provider Demographics
NPI:1225481591
Name:RODRIGUEZ, MICHELLE PHILLIPS
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:PHILLIPS
Last Name:RODRIGUEZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:605 NEWFIELD RD
Mailing Address - Street 2:
Mailing Address - City:GLEN BURNIE
Mailing Address - State:MD
Mailing Address - Zip Code:21061-3324
Mailing Address - Country:US
Mailing Address - Phone:443-694-5220
Mailing Address - Fax:
Practice Address - Street 1:310 GENESIS WAY
Practice Address - Street 2:
Practice Address - City:SEVERNA PARK
Practice Address - State:MD
Practice Address - Zip Code:21146-1762
Practice Address - Country:US
Practice Address - Phone:443-694-5220
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-21
Last Update Date:2016-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDA4495225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant