Provider Demographics
NPI:1285066928
Name:DAVIS, MICHELLE LYNN (PTA)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:LYNN
Last Name:DAVIS
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2139 N 12TH ST
Mailing Address - Street 2:SUITE 3
Mailing Address - City:GRAND JUNCTION
Mailing Address - State:CO
Mailing Address - Zip Code:81501-2901
Mailing Address - Country:US
Mailing Address - Phone:970-245-0511
Mailing Address - Fax:970-245-1025
Practice Address - Street 1:2139 N 12TH ST
Practice Address - Street 2:SUITE 3
Practice Address - City:GRAND JUNCTION
Practice Address - State:CO
Practice Address - Zip Code:81501-2901
Practice Address - Country:US
Practice Address - Phone:970-245-0511
Practice Address - Fax:970-245-1025
Is Sole Proprietor?:No
Enumeration Date:2013-08-05
Last Update Date:2013-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COPTA.0012709225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant