Provider Demographics
NPI:1790734333
Name:VANLAETHEM, MICHELLE A (RPT)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:A
Last Name:VANLAETHEM
Suffix:
Gender:F
Credentials:RPT
Other - Prefix:
Other - First Name:MICHELLE
Other - Middle Name:A
Other - Last Name:LE COMPTE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RPT
Mailing Address - Street 1:200 UNICORN PARK DR STE 201
Mailing Address - Street 2:
Mailing Address - City:WOBURN
Mailing Address - State:MA
Mailing Address - Zip Code:01801-3342
Mailing Address - Country:US
Mailing Address - Phone:781-782-1300
Mailing Address - Fax:781-782-1350
Practice Address - Street 1:200 UNICORN PARK DR STE 201
Practice Address - Street 2:
Practice Address - City:WOBURN
Practice Address - State:MA
Practice Address - Zip Code:01801
Practice Address - Country:US
Practice Address - Phone:781-782-1300
Practice Address - Fax:781-782-1350
Is Sole Proprietor?:No
Enumeration Date:2006-05-10
Last Update Date:2018-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA17795225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA4788150001Medicare NSC
MAY68289Medicare UPIN