Provider Demographics
NPI:1417378423
Name:FETRICK, MICHELLE (DPT)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:FETRICK
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:PO BOX 89
Mailing Address - Street 2:
Mailing Address - City:CHEHALIS
Mailing Address - State:WA
Mailing Address - Zip Code:98532-0089
Mailing Address - Country:US
Mailing Address - Phone:360-740-0888
Mailing Address - Fax:360-740-0555
Practice Address - Street 1:4001 HARRISON AVE NW
Practice Address - Street 2:STE 102
Practice Address - City:OLYMPIA
Practice Address - State:WA
Practice Address - Zip Code:98502-5084
Practice Address - Country:US
Practice Address - Phone:360-956-3627
Practice Address - Fax:360-740-0555
Is Sole Proprietor?:Yes
Enumeration Date:2013-12-17
Last Update Date:2015-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPT 60113648225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist