Provider Demographics
NPI:1710326913
Name:STACHE, MICHELLE B (PTA)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:B
Last Name:STACHE
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:N740 WINDSWAY CT
Mailing Address - Street 2:
Mailing Address - City:FREMONT
Mailing Address - State:WI
Mailing Address - Zip Code:54940-9184
Mailing Address - Country:US
Mailing Address - Phone:920-470-1165
Mailing Address - Fax:
Practice Address - Street 1:1335 S ONEIDA ST
Practice Address - Street 2:
Practice Address - City:APPLETON
Practice Address - State:WI
Practice Address - Zip Code:54915-1351
Practice Address - Country:US
Practice Address - Phone:920-731-6646
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-06-20
Last Update Date:2013-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI601-019225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant