Provider Demographics
NPI:1306916416
Name:SUTHERLAND, MICHELLE JENNIFER (PT, PCS)
Entity type:Individual
Prefix:MRS
First Name:MICHELLE
Middle Name:JENNIFER
Last Name:SUTHERLAND
Suffix:
Gender:F
Credentials:PT, PCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3328 BEMISS RD
Mailing Address - Street 2:
Mailing Address - City:VALDOSTA
Mailing Address - State:GA
Mailing Address - Zip Code:31605-7014
Mailing Address - Country:US
Mailing Address - Phone:229-244-1201
Mailing Address - Fax:229-244-1207
Practice Address - Street 1:3328 BEMISS RD
Practice Address - Street 2:
Practice Address - City:VALDOSTA
Practice Address - State:GA
Practice Address - Zip Code:31605-7014
Practice Address - Country:US
Practice Address - Phone:229-244-1201
Practice Address - Fax:229-244-1207
Is Sole Proprietor?:No
Enumeration Date:2006-11-08
Last Update Date:2008-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPT007469225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000957635CMedicaid