Provider Demographics
NPI:1215265608
Name:SPROSS, MICHELLE SANDRA (PT)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:SANDRA
Last Name:SPROSS
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:MICHELLE
Other - Middle Name:SANDRA
Other - Last Name:KOCH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3614 NE WILLOW WAY
Mailing Address - Street 2:
Mailing Address - City:LAWTON
Mailing Address - State:OK
Mailing Address - Zip Code:73507-4200
Mailing Address - Country:US
Mailing Address - Phone:512-656-7630
Mailing Address - Fax:
Practice Address - Street 1:3614 NE WILLOW WAY
Practice Address - Street 2:
Practice Address - City:LAWTON
Practice Address - State:OK
Practice Address - Zip Code:73507-4200
Practice Address - Country:US
Practice Address - Phone:512-656-7630
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-11-24
Last Update Date:2009-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1140325225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist