Healthcare Provider Details

I. General information

NPI: 1669569273
Provider Name (Legal Business Name): MICHELLE ROSE BALLARD R.P.T.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: MICHELLE ROSE SMITH R.P.T.

II. Dates (important events)

Enumeration Date: 10/06/2006
Last Update Date: 11/02/2020
Certification Date: 11/02/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

501 BURNS AVE
LAKE WALES FL
33853-3335
US

IV. Provider business mailing address

501 BURNS AVE
LAKE WALES FL
33853-3335
US

V. Phone/Fax

Practice location:
  • Phone: 863-679-3338
  • Fax: 888-871-0887
Mailing address:
  • Phone: 863-679-3338
  • Fax: 888-871-0887

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT22565
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: