Provider Demographics
NPI:1780860122
Name:NIDA, MICHELLE (PTA)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:NIDA
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 1:58 PRIVATE DRIVE 699
Mailing Address - Street 2:
Mailing Address - City:WILLOW WOOD
Mailing Address - State:OH
Mailing Address - Zip Code:45696-8949
Mailing Address - Country:US
Mailing Address - Phone:740-867-0817
Mailing Address - Fax:
Practice Address - Street 1:144 S CAROL MALONE BLVD
Practice Address - Street 2:
Practice Address - City:GRAYSON
Practice Address - State:KY
Practice Address - Zip Code:41143-1352
Practice Address - Country:US
Practice Address - Phone:606-474-7901
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-16
Last Update Date:2008-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYA01657225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant