Provider Demographics
NPI:1316161698
Name:MIRKOVIC, MICHELLE MASON (PT)
Entity type:Individual
Prefix:MRS
First Name:MICHELLE
Middle Name:MASON
Last Name:MIRKOVIC
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2917 FONDREN DR
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75205-1913
Mailing Address - Country:US
Mailing Address - Phone:214-373-3378
Mailing Address - Fax:
Practice Address - Street 1:8140 WALNUT HILL LN STE 925
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75231-4372
Practice Address - Country:US
Practice Address - Phone:214-345-1695
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1052496225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist