MEDICARE: MICHELLE FETRICK DPT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225100000X	Physical Therapist	PT 60113648	WA

General Provider Information

NPI Number	:	1417378423
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MICHELLE FETRICK DPT

Provider Business Mailing Address
First Line	:	PO BOX 89
Second Line	:
City	:	CHEHALIS
State	:	WA
Zip	:	98532-0089
Country	:	US
Telephone Number	:	360-740-0888
Fax Number	:	360-740-0555

Provider Business Practice Location Address
First Line	:	4001 HARRISON AVE NW
Second Line	:	STE 102
City	:	OLYMPIA
State	:	WA
Zip	:	98502-5084
Country	:	US
Telephone Number	:	360-956-3627
Fax Number	:	360-740-0555

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/17/2013
Last Update Date	:	11/10/2015

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