Provider Demographics
NPI:1669253001
Name:MICHAELSEN, MICHAEL R (PTA)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:R
Last Name:MICHAELSEN
Suffix:
Gender:M
Credentials:PTA
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 891392
Mailing Address - Street 2:
Mailing Address - City:TEMECULA
Mailing Address - State:CA
Mailing Address - Zip Code:92589-1392
Mailing Address - Country:US
Mailing Address - Phone:951-775-5015
Mailing Address - Fax:
Practice Address - Street 1:26415 SAINT MICHEL LN
Practice Address - Street 2:
Practice Address - City:MURRIETA
Practice Address - State:CA
Practice Address - Zip Code:92563-6091
Practice Address - Country:US
Practice Address - Phone:951-775-5015
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-10-11
Last Update Date:2023-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA48587225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant