Provider Demographics
NPI:1508644980
Name:GILES, MICHELLE SUSANNE (PT)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:SUSANNE
Last Name:GILES
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:MICHELLE
Other - Middle Name:SUSANNE
Other - Last Name:STASSFORTH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:8282 WHITE OAK AVE STE 107
Mailing Address - Street 2:
Mailing Address - City:RANCHO CUCAMONGA
Mailing Address - State:CA
Mailing Address - Zip Code:91730-7681
Mailing Address - Country:US
Mailing Address - Phone:909-222-2745
Mailing Address - Fax:
Practice Address - Street 1:8282 WHITE OAK AVE STE 107
Practice Address - Street 2:
Practice Address - City:RANCHO CUCAMONGA
Practice Address - State:CA
Practice Address - Zip Code:91730-7681
Practice Address - Country:US
Practice Address - Phone:909-222-2745
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-09-18
Last Update Date:2023-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA3046672251P0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics