Provider Demographics
NPI:1821850223
Name:MATSUMOTO, MICHELLE KATHLEEN (PT, DPT)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:KATHLEEN
Last Name:MATSUMOTO
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5700 HARPER DR NE STE 110
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87109-3540
Mailing Address - Country:US
Mailing Address - Phone:505-823-9166
Mailing Address - Fax:
Practice Address - Street 1:5700 HARPER DR NE STE 110
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87109-3540
Practice Address - Country:US
Practice Address - Phone:505-823-9166
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-30
Last Update Date:2024-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
2251X0800X
NM40312251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic