Provider Demographics
NPI:1780795690
Name:SHERRY, MICHELLE MARIE (PT)
Entity type:Individual
Prefix:MRS
First Name:MICHELLE
Middle Name:MARIE
Last Name:SHERRY
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:MICHELLE
Other - Middle Name:MARIE
Other - Last Name:RACKERS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:3301 BERRYWOOD DRIVE
Mailing Address - Street 2:SUITE 204
Mailing Address - City:COLUMBIA
Mailing Address - State:MO
Mailing Address - Zip Code:65201
Mailing Address - Country:US
Mailing Address - Phone:573-449-8771
Mailing Address - Fax:573-449-6563
Practice Address - Street 1:1002 DIAMOND RIDGE
Practice Address - Street 2:SUITE 800
Practice Address - City:JEFFERSON CITY
Practice Address - State:MO
Practice Address - Zip Code:65109
Practice Address - Country:US
Practice Address - Phone:573-761-9360
Practice Address - Fax:573-761-9362
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2008-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2003027561225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOL35E996Medicare PIN