Provider Demographics
NPI:1629242177
Name:FORD, MICHELLE L (PT)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:L
Last Name:FORD
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:MICHELLE
Other - Middle Name:L
Other - Last Name:STODOLA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1808 W BELTLINE HWY
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53713-2334
Mailing Address - Country:US
Mailing Address - Phone:608-250-1497
Mailing Address - Fax:608-250-1384
Practice Address - Street 1:10 TOWER DR
Practice Address - Street 2:
Practice Address - City:SUN PRAIRIE
Practice Address - State:WI
Practice Address - Zip Code:53590-1239
Practice Address - Country:US
Practice Address - Phone:608-825-3500
Practice Address - Fax:608-825-3598
Is Sole Proprietor?:No
Enumeration Date:2008-04-16
Last Update Date:2020-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI6493-024225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1629242177Medicaid