Provider Demographics
NPI:1649041633
Name:CLOSS, MICHELLE DARLENE (LMT)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:DARLENE
Last Name:CLOSS
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2315 N PAGE SPRINGS RD
Mailing Address - Street 2:
Mailing Address - City:CORNVILLE
Mailing Address - State:AZ
Mailing Address - Zip Code:86325-6108
Mailing Address - Country:US
Mailing Address - Phone:520-425-4650
Mailing Address - Fax:
Practice Address - Street 1:1590 WILLOW CREEK RD
Practice Address - Street 2:
Practice Address - City:PRESCOTT
Practice Address - State:AZ
Practice Address - Zip Code:86301-1164
Practice Address - Country:US
Practice Address - Phone:928-227-1899
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-10
Last Update Date:2024-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZMT-27530225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist