Provider Demographics
NPI:1013313113
Name:PERSE, MICHELLE (PT, DPT)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:PERSE
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:MICHELLE
Other - Middle Name:
Other - Last Name:DUCY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4115 CLUB MANOR DRIVE
Mailing Address - Street 2:
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81008
Mailing Address - Country:US
Mailing Address - Phone:719-568-9790
Mailing Address - Fax:
Practice Address - Street 1:4115 CLUB MANOR DRIVE
Practice Address - Street 2:
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81008
Practice Address - Country:US
Practice Address - Phone:719-568-9790
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-11-17
Last Update Date:2023-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COPTL.0013020225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO96254742Medicaid
CO96254742Medicaid