Healthcare Provider Details

I. General information

NPI: 1326204157
Provider Name (Legal Business Name): MICHELLE L CISSELL DPT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/31/2008
Last Update Date: 02/05/2025
Certification Date: 02/05/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20905 E 12 MILE RD
ROSEVILLE MI
48066-6501
US

IV. Provider business mailing address

33900 HARPER AVE SUITE 104
CLINTON TOWNSHIP MI
48035-4258
US

V. Phone/Fax

Practice location:
  • Phone: 586-204-0070
  • Fax: 586-204-0080
Mailing address:
  • Phone: 586-416-9100
  • Fax: 586-416-9103

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT34713
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number5501017759
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: