Provider Demographics
NPI:1326204157
Name:CISSELL, MICHELLE L (DPT)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:L
Last Name:CISSELL
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:33900 HARPER AVE
Mailing Address - Street 2:SUITE 104
Mailing Address - City:CLINTON TOWNSHIP
Mailing Address - State:MI
Mailing Address - Zip Code:48035-4258
Mailing Address - Country:US
Mailing Address - Phone:586-416-9100
Mailing Address - Fax:586-416-9103
Practice Address - Street 1:20905 E 12 MILE RD
Practice Address - Street 2:
Practice Address - City:ROSEVILLE
Practice Address - State:MI
Practice Address - Zip Code:48066-6501
Practice Address - Country:US
Practice Address - Phone:586-204-0070
Practice Address - Fax:586-204-0080
Is Sole Proprietor?:No
Enumeration Date:2008-07-31
Last Update Date:2022-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT34713225100000X
MI5501017759225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW15428OtherMEDICARE GROUP ID
CAW15428OtherMEDICARE GROUP ID