Provider Demographics
NPI:1235672742
Name:GILLAN, MICHELLE (PTA)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:GILLAN
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5715 LAMOS RD
Mailing Address - Street 2:
Mailing Address - City:WHITEHALL
Mailing Address - State:MI
Mailing Address - Zip Code:49461-9616
Mailing Address - Country:US
Mailing Address - Phone:231-981-5149
Mailing Address - Fax:
Practice Address - Street 1:5715 LAMOS RD
Practice Address - Street 2:
Practice Address - City:WHITEHALL
Practice Address - State:MI
Practice Address - Zip Code:49461-9616
Practice Address - Country:US
Practice Address - Phone:231-981-5149
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-12-01
Last Update Date:2016-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI7501002314225700000X
MI5502002740225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist