Provider Demographics
NPI:1346281565
Name:QUIRK, MICHELLE
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:QUIRK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:435 HARTFORD TPKE
Mailing Address - Street 2:SUITE U
Mailing Address - City:VERNON
Mailing Address - State:CT
Mailing Address - Zip Code:06066-4852
Mailing Address - Country:US
Mailing Address - Phone:860-979-1611
Mailing Address - Fax:203-866-3014
Practice Address - Street 1:145 HAZARD AVE
Practice Address - Street 2:SUITE B
Practice Address - City:ENFIELD
Practice Address - State:CT
Practice Address - Zip Code:06082-4521
Practice Address - Country:US
Practice Address - Phone:860-265-2571
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-09
Last Update Date:2016-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT005596174400000X, 225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004167278Medicaid
CT080005596CT27OtherBCBS
CT080005596CT27OtherBCBS