Provider Demographics
NPI:1356495691
Name:RANDALL, MICHELE T (MSPT)
Entity type:Individual
Prefix:MS
First Name:MICHELE
Middle Name:T
Last Name:RANDALL
Suffix:
Gender:F
Credentials:MSPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 504
Mailing Address - Street 2:
Mailing Address - City:ROME
Mailing Address - State:GA
Mailing Address - Zip Code:30162-0504
Mailing Address - Country:US
Mailing Address - Phone:706-291-1780
Mailing Address - Fax:706-291-1782
Practice Address - Street 1:3 JOHN DAVENPORT DR NW
Practice Address - Street 2:
Practice Address - City:ROME
Practice Address - State:GA
Practice Address - Zip Code:30165-2535
Practice Address - Country:US
Practice Address - Phone:706-291-1780
Practice Address - Fax:706-291-1782
Is Sole Proprietor?:No
Enumeration Date:2007-01-23
Last Update Date:2018-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA004863225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA299822311AMedicaid
GA299822311AMedicaid