Provider Demographics
NPI:1316547201
Name:MAILLOUX, MICHELLE JANE (PT, DPT)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:JANE
Last Name:MAILLOUX
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:41 BRIAR AVE
Mailing Address - Street 2:
Mailing Address - City:LOWELL
Mailing Address - State:MA
Mailing Address - Zip Code:01852-1641
Mailing Address - Country:US
Mailing Address - Phone:978-761-5322
Mailing Address - Fax:
Practice Address - Street 1:484 MAIN ST STE 600
Practice Address - Street 2:
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01608-1881
Practice Address - Country:US
Practice Address - Phone:800-244-2756
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-29
Last Update Date:2020-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA251872081S0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2081S0010XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationSports Medicine