Provider Demographics
NPI:1891220430
Name:FIRESTONE, MICHELLYN
Entity Type:Individual
Prefix:
First Name:MICHELLYN
Middle Name:
Last Name:FIRESTONE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2463 CROWNCREST DR
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23233-2517
Mailing Address - Country:US
Mailing Address - Phone:804-908-0506
Mailing Address - Fax:
Practice Address - Street 1:2463 CROWNCREST DRIVE
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23233
Practice Address - Country:US
Practice Address - Phone:804-908-0506
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-04-20
Last Update Date:2017-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2305206299225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist