Provider Demographics
NPI:1205907433
Name:DWYER, MICHELLE ANN (DPT)
Entity type:Individual
Prefix:MS
First Name:MICHELLE
Middle Name:ANN
Last Name:DWYER
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:930 1/2 MICHIGAN AVE
Mailing Address - Street 2:
Mailing Address - City:EVANSTON
Mailing Address - State:IL
Mailing Address - Zip Code:60202-1495
Mailing Address - Country:US
Mailing Address - Phone:847-414-4723
Mailing Address - Fax:
Practice Address - Street 1:930 1/2 MICHIGAN AVE
Practice Address - Street 2:
Practice Address - City:EVANSTON
Practice Address - State:IL
Practice Address - Zip Code:60202-1495
Practice Address - Country:US
Practice Address - Phone:847-414-4723
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-10
Last Update Date:2008-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070.012699225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist