Provider Demographics
NPI:1316173735
Name:DURHAM, MICHELLE DAWN (LPTA)
Entity type:Individual
Prefix:MS
First Name:MICHELLE
Middle Name:DAWN
Last Name:DURHAM
Suffix:
Gender:F
Credentials:LPTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:302 BARNEY CV
Mailing Address - Street 2:
Mailing Address - City:WHITE HALL
Mailing Address - State:AR
Mailing Address - Zip Code:71602-3689
Mailing Address - Country:US
Mailing Address - Phone:870-879-0638
Mailing Address - Fax:
Practice Address - Street 1:6400 TRINITY DR
Practice Address - Street 2:
Practice Address - City:PINE BLUFF
Practice Address - State:AR
Practice Address - Zip Code:71603-7802
Practice Address - Country:US
Practice Address - Phone:870-879-0638
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-06-01
Last Update Date:2009-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARPTA 1459225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist