Provider Demographics
NPI:1245720622
Name:THORESON, MICHELLE JEAN (PT)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:JEAN
Last Name:THORESON
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:MICHELLE
Other - Middle Name:JEAN
Other - Last Name:RICHART
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3411 HAYES ST APT 526
Mailing Address - Street 2:
Mailing Address - City:NEWBERG
Mailing Address - State:OR
Mailing Address - Zip Code:97132-1458
Mailing Address - Country:US
Mailing Address - Phone:320-241-7072
Mailing Address - Fax:
Practice Address - Street 1:3445 BOONE RD SE
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97317-9336
Practice Address - Country:US
Practice Address - Phone:503-576-3000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-11
Last Update Date:2018-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR62728225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist