Provider Demographics
NPI:1568407054
Name:REISIG, MICHELLE LYNN (PT)
Entity Type:Individual
Prefix:MS
First Name:MICHELLE
Middle Name:LYNN
Last Name:REISIG
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 1:415 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:CANYONVILLE
Mailing Address - State:OR
Mailing Address - Zip Code:97417-9646
Mailing Address - Country:US
Mailing Address - Phone:541-476-2502
Mailing Address - Fax:541-476-2397
Practice Address - Street 1:415 S MAIN ST
Practice Address - Street 2:
Practice Address - City:CANYONVILLE
Practice Address - State:OR
Practice Address - Zip Code:97417-9646
Practice Address - Country:US
Practice Address - Phone:541-476-2502
Practice Address - Fax:541-476-2397
Is Sole Proprietor?:No
Enumeration Date:2006-06-18
Last Update Date:2013-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR4654225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR134555Medicare UPIN