Provider Demographics
NPI:1609277169
Name:TULLOUS, MICHELLE (LMT)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:TULLOUS
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1900 SCOFIELD RIDGE PKWY
Mailing Address - Street 2:APT 803
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78727-1600
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2525 W ANDERSON LN
Practice Address - Street 2:SUITE SP5
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78757-1180
Practice Address - Country:US
Practice Address - Phone:512-461-4261
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-15
Last Update Date:2014-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXMT110228225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist