Provider Demographics
NPI:1427354257
Name:SPRAGUE, MICHAEL WILLIAM (PT, DPT)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:WILLIAM
Last Name:SPRAGUE
Suffix:
Gender:M
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1411 FALLS AVE E
Mailing Address - Street 2:SUITE 105
Mailing Address - City:TWIN FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83301-3455
Mailing Address - Country:US
Mailing Address - Phone:208-736-2574
Mailing Address - Fax:208-736-2594
Practice Address - Street 1:1411 FALLS AVE E
Practice Address - Street 2:SUITE 105
Practice Address - City:TWIN FALLS
Practice Address - State:ID
Practice Address - Zip Code:83301-3455
Practice Address - Country:US
Practice Address - Phone:208-736-2574
Practice Address - Fax:208-736-2594
Is Sole Proprietor?:No
Enumeration Date:2011-01-26
Last Update Date:2011-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1202581225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist