Provider Demographics
NPI:1821016577
Name:FALL, MICHAEL P (PT)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:P
Last Name:FALL
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1707 NW SAINT LUCIE WEST BLVD STE 188
Mailing Address - Street 2:
Mailing Address - City:PORT SAINT LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34986-2521
Mailing Address - Country:US
Mailing Address - Phone:772-878-3322
Mailing Address - Fax:772-878-5030
Practice Address - Street 1:162 MOUNTAIN RD
Practice Address - Street 2:
Practice Address - City:SUFFIELD
Practice Address - State:CT
Practice Address - Zip Code:06078-2091
Practice Address - Country:US
Practice Address - Phone:860-668-9589
Practice Address - Fax:860-668-9802
Is Sole Proprietor?:No
Enumeration Date:2006-07-18
Last Update Date:2020-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT003155225100000X
FLPT33481225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT650000623Medicare ID - Type Unspecified