Provider Demographics
NPI:1740477892
Name:NATIVIDAD, MICHELLE ROXAS (PT)
Entity type:Individual
Prefix:MISS
First Name:MICHELLE
Middle Name:ROXAS
Last Name:NATIVIDAD
Suffix:
Gender:
Credentials:PT
Other - Prefix:
Other - First Name:MICHELLE
Other - Middle Name:
Other - Last Name:NATIVIDAD LOPEZ
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PT
Mailing Address - Street 1:111 CENTRE AVE UNIT 164
Mailing Address - Street 2:
Mailing Address - City:NEW ROCHELLE
Mailing Address - State:NY
Mailing Address - Zip Code:10801-7276
Mailing Address - Country:US
Mailing Address - Phone:818-919-8861
Mailing Address - Fax:
Practice Address - Street 1:111 CENTRE AVE UNIT 164
Practice Address - Street 2:
Practice Address - City:NEW ROCHELLE
Practice Address - State:NY
Practice Address - Zip Code:10801-7276
Practice Address - Country:US
Practice Address - Phone:818-919-8861
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-10-02
Last Update Date:2025-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY028628225100000X
NY028628-1208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY028628-1OtherLISCENSE