Provider Demographics
NPI:1689103558
Name:GANIBAN, MICHELLE R (PT)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:R
Last Name:GANIBAN
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2750 GATEWAY OAKS DR STE 310
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95833-3658
Mailing Address - Country:US
Mailing Address - Phone:916-887-7398
Mailing Address - Fax:916-503-3886
Practice Address - Street 1:1201 ALHAMBRA BLVD STE 210
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95816-5241
Practice Address - Country:US
Practice Address - Phone:916-731-7900
Practice Address - Fax:916-731-7315
Is Sole Proprietor?:No
Enumeration Date:2017-06-05
Last Update Date:2017-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT39307225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist