MEDICARE: MICHELLE DESPRES

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225100000X	Physical Therapist

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	17888	OTHER	FL	LICENSE#

General Provider Information

NPI Number	:	1235216235
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MICHELLE DESPRES

Provider Business Mailing Address
First Line	:	5921 PIPER GLEN BLVD
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32222-1345
Country	:	US
Telephone Number	:	904-317-9003
Fax Number	:

Provider Business Practice Location Address
First Line	:	7033 COMMONWEALTH AVE STE 2
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32220-2831
Country	:	US
Telephone Number	:	904-378-3202
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/01/2006
Last Update Date	:	07/08/2007

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Directions to “ MICHELLE DESPRES ” Practice Location

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