Provider Demographics
NPI:1497865588
Name:KRALL, MICHELLE ANN (PT)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:ANN
Last Name:KRALL
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 1:2080 CENTURY PARK E
Mailing Address - Street 2:SUITE 205
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90067-2001
Mailing Address - Country:US
Mailing Address - Phone:310-553-2519
Mailing Address - Fax:310-553-5842
Practice Address - Street 1:2080 CENTURY PARK E
Practice Address - Street 2:SUITE 205
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90067-2001
Practice Address - Country:US
Practice Address - Phone:310-553-2519
Practice Address - Fax:310-553-5842
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-30
Last Update Date:2007-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT18453208100000X
CAIMF 54196106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAWPT18453AMedicare PIN