Provider Demographics
NPI:1558917476
Name:GORETH, MICHELLE RENAE (PTA)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:RENAE
Last Name:GORETH
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 1:719 S OAKWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:GENESEO
Mailing Address - State:IL
Mailing Address - Zip Code:61254-1756
Mailing Address - Country:US
Mailing Address - Phone:309-944-5464
Mailing Address - Fax:
Practice Address - Street 1:719 S OAKWOOD AVE
Practice Address - Street 2:
Practice Address - City:GENESEO
Practice Address - State:IL
Practice Address - Zip Code:61254-1756
Practice Address - Country:US
Practice Address - Phone:563-650-7169
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-15
Last Update Date:2019-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL160004145225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant