Provider Demographics
NPI:1952407298
Name:KLUKOS, MICHELE ELISA (MS,PT)
Entity Type:Individual
Prefix:MS
First Name:MICHELE
Middle Name:ELISA
Last Name:KLUKOS
Suffix:
Gender:F
Credentials:MS,PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1231 W MAIN ST
Mailing Address - Street 2:SUITE B
Mailing Address - City:FREMONT
Mailing Address - State:MI
Mailing Address - Zip Code:49412-1484
Mailing Address - Country:US
Mailing Address - Phone:231-924-8777
Mailing Address - Fax:231-924-8776
Practice Address - Street 1:1231 W MAIN ST
Practice Address - Street 2:SUITE B
Practice Address - City:FREMONT
Practice Address - State:MI
Practice Address - Zip Code:49412-1484
Practice Address - Country:US
Practice Address - Phone:231-924-8777
Practice Address - Fax:231-924-8776
Is Sole Proprietor?:No
Enumeration Date:2006-09-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIL708615225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4717630Medicaid
MI30609OtherBCBS
MI236619Medicare ID - Type Unspecified