Provider Demographics
NPI:1679265839
Name:LAFAVE, MICHELLE (DPT)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:LAFAVE
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 1:102 W FULTON ST
Mailing Address - Street 2:
Mailing Address - City:EDGERTON
Mailing Address - State:WI
Mailing Address - Zip Code:53534-1839
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:102 W FULTON ST
Practice Address - Street 2:
Practice Address - City:EDGERTON
Practice Address - State:WI
Practice Address - Zip Code:53534-1839
Practice Address - Country:US
Practice Address - Phone:608-561-7733
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-24
Last Update Date:2023-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI16314-24225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist