Provider Demographics
NPI:1790411296
Name:DETTLAFF, MICHAEL CHRISTOPHER (PTA)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:CHRISTOPHER
Last Name:DETTLAFF
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1205 BRANUM CT
Mailing Address - Street 2:
Mailing Address - City:APEX
Mailing Address - State:NC
Mailing Address - Zip Code:27523-5527
Mailing Address - Country:US
Mailing Address - Phone:919-275-5998
Mailing Address - Fax:
Practice Address - Street 1:101 GREEN CEDAR LN
Practice Address - Street 2:
Practice Address - City:CHAPEL HILL
Practice Address - State:NC
Practice Address - Zip Code:27517-7222
Practice Address - Country:US
Practice Address - Phone:919-275-5998
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-27
Last Update Date:2022-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCA7838225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant