Provider Demographics
NPI:1952630923
Name:WORTHINGTON, MICHELE ANN
Entity Type:Individual
Prefix:
First Name:MICHELE
Middle Name:ANN
Last Name:WORTHINGTON
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 1:2930 BEALE ST
Mailing Address - Street 2:
Mailing Address - City:TITUSVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32796-1941
Mailing Address - Country:US
Mailing Address - Phone:321-427-2306
Mailing Address - Fax:
Practice Address - Street 1:2930 BEALE ST
Practice Address - Street 2:
Practice Address - City:TITUSVILLE
Practice Address - State:FL
Practice Address - Zip Code:32796-1941
Practice Address - Country:US
Practice Address - Phone:321-427-2306
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-12-21
Last Update Date:2009-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPTA2057225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant