Provider Demographics
NPI:1265687180
Name:CONLIN, MICHELLE HAVICE (MPT)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:HAVICE
Last Name:CONLIN
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:
Other - First Name:ANDREA
Other - Middle Name:MICHELLE
Other - Last Name:HAVICE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MPT
Mailing Address - Street 1:1919 65TH AVE STE 3
Mailing Address - Street 2:
Mailing Address - City:GREELEY
Mailing Address - State:CO
Mailing Address - Zip Code:80634-7965
Mailing Address - Country:US
Mailing Address - Phone:970-302-4322
Mailing Address - Fax:888-432-0938
Practice Address - Street 1:1919 65TH AVE STE 3
Practice Address - Street 2:
Practice Address - City:GREELEY
Practice Address - State:CO
Practice Address - Zip Code:80634
Practice Address - Country:US
Practice Address - Phone:970-302-4322
Practice Address - Fax:888-432-0938
Is Sole Proprietor?:Yes
Enumeration Date:2008-11-19
Last Update Date:2018-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO6380225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
COCOB4290Medicare UPIN