Provider Demographics
NPI:1811031206
Name:BORST, MICHELE DIANE (PT)
Entity Type:Individual
Prefix:
First Name:MICHELE
Middle Name:DIANE
Last Name:BORST
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2601A DEMERE RD
Mailing Address - Street 2:
Mailing Address - City:ST SIMONS ISLAND
Mailing Address - State:GA
Mailing Address - Zip Code:31522-1614
Mailing Address - Country:US
Mailing Address - Phone:912-634-9945
Mailing Address - Fax:912-638-1584
Practice Address - Street 1:2601A DEMERE RD
Practice Address - Street 2:
Practice Address - City:ST SIMONS ISLAND
Practice Address - State:GA
Practice Address - Zip Code:31522-1614
Practice Address - Country:US
Practice Address - Phone:912-634-9945
Practice Address - Fax:912-638-1584
Is Sole Proprietor?:No
Enumeration Date:2007-02-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPT008488225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAPT008488OtherPT LICENSE NUMBER