Provider Demographics
NPI:1922350859
Name:CUPERTINO, MICHELLE R (PTA)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:R
Last Name:CUPERTINO
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4010 N OCEAN BLVD
Mailing Address - Street 2:2ND FLOOR
Mailing Address - City:FORT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33308-6420
Mailing Address - Country:US
Mailing Address - Phone:561-672-9615
Mailing Address - Fax:954-241-6726
Practice Address - Street 1:4010 N OCEAN BLVD
Practice Address - Street 2:2ND FLOOR
Practice Address - City:FORT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33308-6420
Practice Address - Country:US
Practice Address - Phone:561-672-9615
Practice Address - Fax:954-241-6726
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-02
Last Update Date:2012-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPTA23549225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant