Provider Demographics
NPI:1699256321
Name:MCKINNEY, MICHELLE (PTA)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:MCKINNEY
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 1:12408 SUNLAND AVE
Mailing Address - Street 2:
Mailing Address - City:RHOME
Mailing Address - State:TX
Mailing Address - Zip Code:76078-6030
Mailing Address - Country:US
Mailing Address - Phone:903-272-9920
Mailing Address - Fax:
Practice Address - Street 1:2224 N CARROLL BLVD
Practice Address - Street 2:
Practice Address - City:DENTON
Practice Address - State:TX
Practice Address - Zip Code:76201-1834
Practice Address - Country:US
Practice Address - Phone:940-387-6656
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-21
Last Update Date:2018-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX2122211OtherPTA LICENSE