MEDICARE: MICHELLE GOTTSCHALK

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

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	3806	OTHER	OK	LICENSE #

General Provider Information

NPI Number	:	1578671889
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MICHELLE GOTTSCHALK

Provider Business Mailing Address
First Line	:	2009 PONY EXPRESS TRAIL
Second Line	:
City	:	EDMOND
State	:	OK
Zip	:	73003-7952
Country	:	US
Telephone Number	:	580-761-3279
Fax Number	:

Provider Business Practice Location Address
First Line	:	1410 FRETZ DR
Second Line	:
City	:	EDMOND
State	:	OK
Zip	:	73003-5782
Country	:	US
Telephone Number	:	405-285-8477
Fax Number	:

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

Provider Enumeration Date	:	08/27/2006
Last Update Date	:	07/01/2010

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Directions to “ MICHELLE GOTTSCHALK ” Practice Location

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