Provider Demographics
NPI:1790379576
Name:FRALEY, MICHAEL GLENN (DPT, ATC)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:GLENN
Last Name:FRALEY
Suffix:
Gender:M
Credentials:DPT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:436 CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:OAK HILL
Mailing Address - State:WV
Mailing Address - Zip Code:25901-3009
Mailing Address - Country:US
Mailing Address - Phone:304-465-3654
Mailing Address - Fax:
Practice Address - Street 1:436 CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:OAK HILL
Practice Address - State:WV
Practice Address - Zip Code:25901-3009
Practice Address - Country:US
Practice Address - Phone:304-465-3654
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-23
Last Update Date:2021-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV004376225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty