Provider Demographics
NPI:1528831765
Name:MICHAELIS, RYAN AUSTIN (LAT, CAT)
Entity type:Individual
Prefix:
First Name:RYAN
Middle Name:AUSTIN
Last Name:MICHAELIS
Suffix:
Gender:M
Credentials:LAT, CAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1862 SWYNFORD LN
Mailing Address - Street 2:
Mailing Address - City:COLLIERVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:38017-8874
Mailing Address - Country:US
Mailing Address - Phone:901-647-3016
Mailing Address - Fax:
Practice Address - Street 1:99 MARKET CENTER DR
Practice Address - Street 2:
Practice Address - City:COLLIERVILLE
Practice Address - State:TN
Practice Address - Zip Code:38017-6913
Practice Address - Country:US
Practice Address - Phone:901-861-9610
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-10-31
Last Update Date:2023-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN31112255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer