Provider Demographics
NPI:1740530633
Name:BIERDEMAN, MICHELLE LEE (LMT)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:LEE
Last Name:BIERDEMAN
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 1:1121 WESTRAC DR S
Mailing Address - Street 2:SUITE 102
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58103-8716
Mailing Address - Country:US
Mailing Address - Phone:701-297-8191
Mailing Address - Fax:
Practice Address - Street 1:1121 WESTRAC DR S
Practice Address - Street 2:SUITE 102
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58103-8716
Practice Address - Country:US
Practice Address - Phone:701-297-8191
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-18
Last Update Date:2012-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND1209225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist