Provider Demographics
NPI:1871850370
Name:ARCHIBALD, MICHELLE R (PT, DPT)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:R
Last Name:ARCHIBALD
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:MICHELLE
Other - Middle Name:
Other - Last Name:LAUGHLIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT, DPT
Mailing Address - Street 1:19015 S. JODI ROAD
Mailing Address - Street 2:SUITE A
Mailing Address - City:MOKENA
Mailing Address - State:IL
Mailing Address - Zip Code:60448-8534
Mailing Address - Country:US
Mailing Address - Phone:708-478-1414
Mailing Address - Fax:708-478-7786
Practice Address - Street 1:6775 PROSPERI DR
Practice Address - Street 2:
Practice Address - City:TINLEY PARK
Practice Address - State:IL
Practice Address - Zip Code:60477-4789
Practice Address - Country:US
Practice Address - Phone:708-429-1260
Practice Address - Fax:708-429-9107
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-20
Last Update Date:2014-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070.017370225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist