Provider Demographics
NPI:1700102498
Name:ANGELO, MICHELLE (DPT)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:ANGELO
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:307 74TH AVENUE NORTH
Mailing Address - Street 2:#4B
Mailing Address - City:MYRTLE BEACH
Mailing Address - State:SC
Mailing Address - Zip Code:29572
Mailing Address - Country:US
Mailing Address - Phone:203-231-9505
Mailing Address - Fax:
Practice Address - Street 1:307 74TH AVE N
Practice Address - Street 2:#4B
Practice Address - City:MYRTLE BEACH
Practice Address - State:SC
Practice Address - Zip Code:29572-3837
Practice Address - Country:US
Practice Address - Phone:203-231-9505
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-04-20
Last Update Date:2010-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC6511225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist