MEDICARE: MICHELLE LYNN DOMINICK-DREYER PTA

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	225200000X	Physical Therapy Assistant	5502000597	MI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	5502000597	OTHER	MI	LICENSE

General Provider Information

NPI Number	:	1568094811
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MICHELLE LYNN DOMINICK-DREYER PTA

Provider Business Mailing Address
First Line	:	4431 BONNYMEDE ST
Second Line	:
City	:	JACKSON
State	:	MI
Zip	:	49201-8511
Country	:	US
Telephone Number	:	517-745-0827
Fax Number	:

Provider Business Practice Location Address
First Line	:	4431 BONNYMEDE ST
Second Line	:
City	:	JACKSON
State	:	MI
Zip	:	49201-8511
Country	:	US
Telephone Number	:	517-745-0827
Fax Number	:

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

Provider Enumeration Date	:	02/05/2020
Last Update Date	:	02/05/2020

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