Provider Demographics
NPI:1841227451
Name:DEBOER, MICHELLE DIANE (ATC)
Entity Type:Individual
Prefix:MISS
First Name:MICHELLE
Middle Name:DIANE
Last Name:DEBOER
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 E TAZEWELL ST
Mailing Address - Street 2:
Mailing Address - City:TREMONT
Mailing Address - State:IL
Mailing Address - Zip Code:61568-8523
Mailing Address - Country:US
Mailing Address - Phone:309-925-5405
Mailing Address - Fax:
Practice Address - Street 1:350 N ILLINOIS AVE
Practice Address - Street 2:
Practice Address - City:MORTON
Practice Address - State:IL
Practice Address - Zip Code:61550-2206
Practice Address - Country:US
Practice Address - Phone:390-266-7182
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer