Provider Demographics
NPI:1396413464
Name:MICELI, BURGUNDIE (LMT)
Entity Type:Individual
Prefix:
First Name:BURGUNDIE
Middle Name:
Last Name:MICELI
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:309 WESTVIEW DR
Mailing Address - Street 2:
Mailing Address - City:MISSOULA
Mailing Address - State:MT
Mailing Address - Zip Code:59803-1527
Mailing Address - Country:US
Mailing Address - Phone:406-298-4969
Mailing Address - Fax:
Practice Address - Street 1:725 W ALDER ST STE 3
Practice Address - Street 2:
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59802-4094
Practice Address - Country:US
Practice Address - Phone:406-298-4969
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-02
Last Update Date:2021-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTLMT-LMT-LIC-20146225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist