Provider Demographics
NPI:1912371915
Name:COBURN, MICHELE (MSPT)
Entity Type:Individual
Prefix:
First Name:MICHELE
Middle Name:
Last Name:COBURN
Suffix:
Gender:F
Credentials:MSPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5 N DORADO CIR APT 1H
Mailing Address - Street 2:
Mailing Address - City:HAUPPAUGE
Mailing Address - State:NY
Mailing Address - Zip Code:11788-4621
Mailing Address - Country:US
Mailing Address - Phone:516-330-1551
Mailing Address - Fax:
Practice Address - Street 1:5 N DORADO CIR APT 1H
Practice Address - Street 2:
Practice Address - City:HAUPPAUGE
Practice Address - State:NY
Practice Address - Zip Code:11788-4621
Practice Address - Country:US
Practice Address - Phone:516-330-1551
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-11-15
Last Update Date:2015-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY020732-12251G0304X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251G0304XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGeriatrics