Provider Demographics
NPI:1336539790
Name:MICHELLE, GINA
Entity Type:Individual
Prefix:
First Name:GINA
Middle Name:
Last Name:MICHELLE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:370 CIRCLE DR
Mailing Address - Street 2:
Mailing Address - City:FORT COLLINS
Mailing Address - State:CO
Mailing Address - Zip Code:80524-4172
Mailing Address - Country:US
Mailing Address - Phone:720-320-7789
Mailing Address - Fax:
Practice Address - Street 1:300 BOARDWALK DR
Practice Address - Street 2:#6A
Practice Address - City:FORT COLLINS
Practice Address - State:CO
Practice Address - Zip Code:80525-3070
Practice Address - Country:US
Practice Address - Phone:720-320-7789
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-01-23
Last Update Date:2015-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO7985225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist