Healthcare Provider Details

I. General information

NPI: 1073680286
Provider Name (Legal Business Name): MICHELLE L MICHALAK ATC CSCS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/30/2006
Last Update Date: 08/07/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5165 ADANSON ST
ORLANDO FL
32804-1331
US

IV. Provider business mailing address

13201 HEATHER MOSS DR #1502
ORLANDO FL
32837-5552
US

V. Phone/Fax

Practice location:
  • Phone: 630-750-3369
  • Fax:
Mailing address:
  • Phone: 630-750-3369
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2081S0010X
TaxonomySports Medicine (Physical Medicine & Rehabilitation) Physician
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: