Provider Demographics
NPI:1639132517
Name:HENNESSEY, MICHELLE (DPT)
Entity Type:Individual
Prefix:DR
First Name:MICHELLE
Middle Name:
Last Name:HENNESSEY
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1001 E BOGARD RD
Mailing Address - Street 2:
Mailing Address - City:WASILLA
Mailing Address - State:AK
Mailing Address - Zip Code:99654-7114
Mailing Address - Country:US
Mailing Address - Phone:907-373-7246
Mailing Address - Fax:907-376-9225
Practice Address - Street 1:1001 E BOGARD RD
Practice Address - Street 2:
Practice Address - City:WASILLA
Practice Address - State:AK
Practice Address - Zip Code:99654-7114
Practice Address - Country:US
Practice Address - Phone:907-373-7246
Practice Address - Fax:907-376-9225
Is Sole Proprietor?:No
Enumeration Date:2006-04-11
Last Update Date:2021-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ6726225100000X, 225100000X
AK100023225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK1683033Medicaid