Provider Demographics
NPI:1316251911
Name:LAVERY, MICHELLE (PTA)
Entity type:Individual
Prefix:MRS
First Name:MICHELLE
Middle Name:
Last Name:LAVERY
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:PO BOX 145
Mailing Address - Street 2:
Mailing Address - City:ROSCOE
Mailing Address - State:NY
Mailing Address - Zip Code:12776-0145
Mailing Address - Country:US
Mailing Address - Phone:607-498-5653
Mailing Address - Fax:607-498-5671
Practice Address - Street 1:45 STEWART AVE
Practice Address - Street 2:
Practice Address - City:ROSCOE
Practice Address - State:NY
Practice Address - Zip Code:12776
Practice Address - Country:US
Practice Address - Phone:607-498-5653
Practice Address - Fax:607-498-5671
Is Sole Proprietor?:Yes
Enumeration Date:2010-08-06
Last Update Date:2010-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0059111174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist