Provider Demographics
NPI:1841401296
Name:THEEMAN, MICHAEL ROBERT (MSPT)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:ROBERT
Last Name:THEEMAN
Suffix:
Gender:M
Credentials:MSPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:44 ELM ST APT 3
Mailing Address - Street 2:
Mailing Address - City:PLATTSBURGH
Mailing Address - State:NY
Mailing Address - Zip Code:12901-1828
Mailing Address - Country:US
Mailing Address - Phone:518-569-7591
Mailing Address - Fax:
Practice Address - Street 1:75 PARK STREET
Practice Address - Street 2:
Practice Address - City:ELIZABETHTOWN
Practice Address - State:NY
Practice Address - Zip Code:12932
Practice Address - Country:US
Practice Address - Phone:518-873-6377
Practice Address - Fax:518-873-2005
Is Sole Proprietor?:No
Enumeration Date:2007-05-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY025807-1225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist