Provider Demographics
NPI:1720550619
Name:ROUDEBUSH, MICHELLE (MASSAGE THERAPIST)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:ROUDEBUSH
Suffix:
Gender:F
Credentials:MASSAGE THERAPIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:111 E GRANT ST
Mailing Address - Street 2:
Mailing Address - City:LA FONTAINE
Mailing Address - State:IN
Mailing Address - Zip Code:46940-9238
Mailing Address - Country:US
Mailing Address - Phone:260-377-9519
Mailing Address - Fax:
Practice Address - Street 1:86 E MAIN ST
Practice Address - Street 2:
Practice Address - City:WABASH
Practice Address - State:IN
Practice Address - Zip Code:46992-3196
Practice Address - Country:US
Practice Address - Phone:260-377-9519
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-12-18
Last Update Date:2018-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN21505618225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist