Provider Demographics
NPI:1265962492
Name:RANDALL, MICHELLE LYNN (LPTA)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:LYNN
Last Name:RANDALL
Suffix:
Gender:F
Credentials:LPTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:355 BOBBITT RD
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:OH
Mailing Address - Zip Code:45177-7525
Mailing Address - Country:US
Mailing Address - Phone:937-552-6097
Mailing Address - Fax:
Practice Address - Street 1:512 CRESCENT DR
Practice Address - Street 2:
Practice Address - City:TROY
Practice Address - State:OH
Practice Address - Zip Code:45373-2718
Practice Address - Country:US
Practice Address - Phone:937-335-7161
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-20
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH10346225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant