Provider Demographics
NPI:1568193209
Name:MALONE, MICHELLE ELAYNE (PTA)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:ELAYNE
Last Name:MALONE
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11511 CRAIG CT APT 307
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63146-6204
Mailing Address - Country:US
Mailing Address - Phone:502-544-3295
Mailing Address - Fax:
Practice Address - Street 1:693 DECKER LN
Practice Address - Street 2:
Practice Address - City:CREVE COEUR
Practice Address - State:MO
Practice Address - Zip Code:63141-6766
Practice Address - Country:US
Practice Address - Phone:314-997-4532
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-23
Last Update Date:2022-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2019031759225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant