Provider Demographics
NPI:1942258330
Name:WALL, MICHELLE (PT)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:WALL
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:MICHELLE
Other - Middle Name:
Other - Last Name:BERKOWITZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:200 NEWPORT CENTER DR
Mailing Address - Street 2:#213
Mailing Address - City:NEWPORT BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92660-7501
Mailing Address - Country:US
Mailing Address - Phone:949-644-1322
Mailing Address - Fax:949-644-0316
Practice Address - Street 1:200 NEWPORT CENTER DR
Practice Address - Street 2:#213
Practice Address - City:NEWPORT BEACH
Practice Address - State:CA
Practice Address - Zip Code:92660-7501
Practice Address - Country:US
Practice Address - Phone:949-644-1322
Practice Address - Fax:949-644-0316
Is Sole Proprietor?:No
Enumeration Date:2006-05-05
Last Update Date:2008-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT25420225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAWPT25420AMedicare PIN