Provider Demographics
NPI:1629613443
Name:WINDSOR, MICHAEL JR (LMT)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:WINDSOR
Suffix:JR
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4606 W JEFFERSON BLVD
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46804-6826
Mailing Address - Country:US
Mailing Address - Phone:260-459-1111
Mailing Address - Fax:260-459-2209
Practice Address - Street 1:4606 W JEFFERSON BLVD
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46804-6826
Practice Address - Country:US
Practice Address - Phone:260-459-1111
Practice Address - Fax:260-459-2209
Is Sole Proprietor?:No
Enumeration Date:2019-11-15
Last Update Date:2020-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
INMT21003391225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist