Provider Demographics
NPI:1275943466
Name:BIDWELL, MICHELLE (PTA)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:BIDWELL
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 1:2010 SW H K DODGEN LOOP STE 201
Mailing Address - Street 2:
Mailing Address - City:TEMPLE
Mailing Address - State:TX
Mailing Address - Zip Code:76504-7056
Mailing Address - Country:US
Mailing Address - Phone:254-774-9991
Mailing Address - Fax:254-774-9980
Practice Address - Street 1:2010 SW H K DODGEN LOOP STE 201
Practice Address - Street 2:
Practice Address - City:TEMPLE
Practice Address - State:TX
Practice Address - Zip Code:76504-7056
Practice Address - Country:US
Practice Address - Phone:254-774-9991
Practice Address - Fax:254-774-9980
Is Sole Proprietor?:Yes
Enumeration Date:2014-04-28
Last Update Date:2014-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX205-7860225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant