Provider Demographics
NPI:1659595288
Name:DECKER, MICHELLE LEE
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:LEE
Last Name:DECKER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:843 LOWER WATERFORD RD
Mailing Address - Street 2:
Mailing Address - City:SAINT JOHNSBURY
Mailing Address - State:VT
Mailing Address - Zip Code:05819-9487
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:843 LOWER WATERFORD RD
Practice Address - Street 2:
Practice Address - City:SAINT JOHNSBURY
Practice Address - State:VT
Practice Address - Zip Code:05819-9487
Practice Address - Country:US
Practice Address - Phone:603-838-2800
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH3042225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist