Provider Demographics
NPI:1588909816
Name:HALVERSON, MICHELLE
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:HALVERSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:36188 CHRISTINE BLVD
Mailing Address - Street 2:
Mailing Address - City:WHITEHALL
Mailing Address - State:WI
Mailing Address - Zip Code:54773-8618
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:620 GRANDVIEW AVE
Practice Address - Street 2:
Practice Address - City:BLAIR
Practice Address - State:WI
Practice Address - Zip Code:54616-1101
Practice Address - Country:US
Practice Address - Phone:608-989-2195
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-11-27
Last Update Date:2019-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1850-19225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100028877Medicaid