Provider Demographics
NPI:1235517046
Name:BORST, MICHAEL (DPT, ATC)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:BORST
Suffix:
Gender:M
Credentials:DPT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:509 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:LA CROSSE
Mailing Address - State:WI
Mailing Address - Zip Code:54601-4004
Mailing Address - Country:US
Mailing Address - Phone:608-351-3049
Mailing Address - Fax:
Practice Address - Street 1:509 MAIN ST
Practice Address - Street 2:
Practice Address - City:LA CROSSE
Practice Address - State:WI
Practice Address - Zip Code:54601
Practice Address - Country:US
Practice Address - Phone:608-351-3049
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-05-12
Last Update Date:2018-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
2255A2300X, 390200000X
WI141752251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program