Provider Demographics
NPI:1356192918
Name:MICHAEL, CONESHA (MT)
Entity type:Individual
Prefix:
First Name:CONESHA
Middle Name:
Last Name:MICHAEL
Suffix:
Gender:F
Credentials:MT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1000 HIGHLAND COLONY PKWY STE 5203
Mailing Address - Street 2:
Mailing Address - City:RIDGELAND
Mailing Address - State:MS
Mailing Address - Zip Code:39157-2079
Mailing Address - Country:US
Mailing Address - Phone:769-798-6814
Mailing Address - Fax:
Practice Address - Street 1:262 IRIS AVE
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39206-3905
Practice Address - Country:US
Practice Address - Phone:769-798-6814
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-04-01
Last Update Date:2024-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS2917225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist