=====================================================
General NPI Number Information
=====================================================
NPI Number | 1093003881
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MRS. MICHELLE DYER DENISON
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/14/2011
-----------------------------------------------------
Last Update Date | 07/14/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 8679 ELMER HILL RD
-----------------------------------------------------
City | ROME
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 13440-9314
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 315-339-4836
-----------------------------------------------------
Fax | 315-339-1742
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8679 ELMER HILL RD
-----------------------------------------------------
City | ROME
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 13440-9314
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 315-339-4836
-----------------------------------------------------
Fax | 315-339-1742
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number | 016607-1
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------