Provider Demographics
NPI:1508036138
Name:BROD, MICHELLE MARIE (MPT)
Entity Type:Individual
Prefix:MISS
First Name:MICHELLE
Middle Name:MARIE
Last Name:BROD
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1276 PEACH WOOD WAY
Mailing Address - Street 2:
Mailing Address - City:UNIONTOWN
Mailing Address - State:OH
Mailing Address - Zip Code:44685-9500
Mailing Address - Country:US
Mailing Address - Phone:330-312-2964
Mailing Address - Fax:
Practice Address - Street 1:2484 W STATE ST
Practice Address - Street 2:
Practice Address - City:ALLIANCE
Practice Address - State:OH
Practice Address - Zip Code:44601-5608
Practice Address - Country:US
Practice Address - Phone:330-829-2339
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-03-11
Last Update Date:2009-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC11485174400000X
OH012442225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7211457Medicaid
NC346512Medicare Oscar/Certification