Provider Demographics
NPI:1750706123
Name:MATHEWSON, MICHELLE (PT)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:MATHEWSON
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:SHELLEY
Other - Middle Name:
Other - Last Name:MATHEWSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PT
Mailing Address - Street 1:PO BOX 7287
Mailing Address - Street 2:
Mailing Address - City:BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97708-7287
Mailing Address - Country:US
Mailing Address - Phone:541-447-6254
Mailing Address - Fax:
Practice Address - Street 1:1201 NE ELM ST
Practice Address - Street 2:
Practice Address - City:PRINEVILLE
Practice Address - State:OR
Practice Address - Zip Code:97754-1206
Practice Address - Country:US
Practice Address - Phone:541-447-6254
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-02-21
Last Update Date:2014-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR04170225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist