Provider Demographics
NPI:1255383691
Name:TAVAKOLIAN, MICHELLE MARION (PT)
Entity type:Individual
Prefix:MRS
First Name:MICHELLE
Middle Name:MARION
Last Name:TAVAKOLIAN
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30836 COAST HWY
Mailing Address - Street 2:
Mailing Address - City:LAGUNA BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92651-8136
Mailing Address - Country:US
Mailing Address - Phone:949-499-9559
Mailing Address - Fax:949-499-1845
Practice Address - Street 1:30836 COAST HWY
Practice Address - Street 2:
Practice Address - City:LAGUNA BEACH
Practice Address - State:CA
Practice Address - Zip Code:92651-8136
Practice Address - Country:US
Practice Address - Phone:949-499-9559
Practice Address - Fax:949-499-1845
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA26646225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAWPT26646AMedicare ID - Type UnspecifiedPRIVPRAC PT MEDICARE