=====================================================
General NPI Number Information
=====================================================
NPI Number | 1114933587
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MICHELLE DOUGLAS PT
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/31/2006
-----------------------------------------------------
Last Update Date | 03/19/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 676 BATTLEFIELD BLVD N STE C
-----------------------------------------------------
City | CHESAPEAKE
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23320-0306
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 757-436-2695
-----------------------------------------------------
Fax | 757-436-2697
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 676 BATTLEFIELD BLVD N STE C
-----------------------------------------------------
City | CHESAPEAKE
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23320-0306
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 757-436-2695
-----------------------------------------------------
Fax | 757-436-2697
-----------------------------------------------------
=====================================================
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 | 2305005425
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------