Provider Demographics
NPI:1245584770
Name:JOHNSON, MICHELLE M (MS, ATC)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:M
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:MS, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24 TURTLE ROCK CT
Mailing Address - Street 2:
Mailing Address - City:NEW PALTZ
Mailing Address - State:NY
Mailing Address - Zip Code:12561-1127
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1 HAWK DR
Practice Address - Street 2:103 ELTING GYMNASIUM
Practice Address - City:NEW PALTZ
Practice Address - State:NY
Practice Address - Zip Code:12561-2447
Practice Address - Country:US
Practice Address - Phone:845-257-3928
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-11-06
Last Update Date:2012-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY001403-12255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer