Provider Demographics
NPI:1609153451
Name:KOMARA, MICHELE CZUCHAN (PT)
Entity Type:Individual
Prefix:MRS
First Name:MICHELE
Middle Name:CZUCHAN
Last Name:KOMARA
Suffix:
Gender:F
Credentials:PT
Other - Prefix:MS
Other - First Name:MICHELE
Other - Middle Name:IRENE
Other - Last Name:CZUCHAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:107 CRAFT ST
Mailing Address - Street 2:
Mailing Address - City:BROWNSVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:15417-9685
Mailing Address - Country:US
Mailing Address - Phone:773-403-4707
Mailing Address - Fax:
Practice Address - Street 1:107 CRAFT ST
Practice Address - Street 2:
Practice Address - City:BROWNSVILLE
Practice Address - State:PA
Practice Address - Zip Code:15417-9685
Practice Address - Country:US
Practice Address - Phone:773-403-4707
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-08
Last Update Date:2019-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPT007071L225100000X
WVPT003711225100000X
FLPT27207225100000X
TX1225853225100000X
IL070.009406225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist