Provider Demographics
NPI:1437270980
Name:STIDSEN, MICHELLE BAKER (PT)
Entity Type:Individual
Prefix:MS
First Name:MICHELLE
Middle Name:BAKER
Last Name:STIDSEN
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1110 PRIM RD
Mailing Address - Street 2:SUITE 1
Mailing Address - City:COLCHESTER
Mailing Address - State:VT
Mailing Address - Zip Code:05446-6403
Mailing Address - Country:US
Mailing Address - Phone:802-860-4461
Mailing Address - Fax:
Practice Address - Street 1:1110 PRIM RD
Practice Address - Street 2:SUITE 1
Practice Address - City:COLCHESTER
Practice Address - State:VT
Practice Address - Zip Code:05446-6403
Practice Address - Country:US
Practice Address - Phone:802-860-4461
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT0400002909225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist