Provider Demographics
NPI:1366858748
Name:WALL, MICHELLE M (PT/DPT, ATC)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:M
Last Name:WALL
Suffix:
Gender:F
Credentials:PT/DPT, ATC
Other - Prefix:
Other - First Name:MICHELLE
Other - Middle Name:
Other - Last Name:RABEDEAUX
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:ATC
Mailing Address - Street 1:3992 133RD CT W
Mailing Address - Street 2:
Mailing Address - City:ROSEMOUNT
Mailing Address - State:MN
Mailing Address - Zip Code:55068-5338
Mailing Address - Country:US
Mailing Address - Phone:641-521-4590
Mailing Address - Fax:
Practice Address - Street 1:3992 133RD CT W
Practice Address - Street 2:
Practice Address - City:ROSEMOUNT
Practice Address - State:MN
Practice Address - Zip Code:55068-5338
Practice Address - Country:US
Practice Address - Phone:641-521-4590
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-07
Last Update Date:2022-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA0744802255A2300X
MN10890225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer