Healthcare Provider Details

I. General information

NPI: 1144397522
Provider Name (Legal Business Name): MICHELLE IRVIN P.T.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/29/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

140 S GILBERT RD
GILBERT AZ
85296-1016
US

IV. Provider business mailing address

1634 E GRAND CANYON DR
CHANDLER AZ
85249-2872
US

V. Phone/Fax

Practice location:
  • Phone: 480-558-5131
  • Fax: 480-507-1616
Mailing address:
  • Phone: 480-664-4882
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number3475
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: