Provider Demographics
NPI:1730534280
Name:BURT, MICHELLE (LMT)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:BURT
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3006 CARSWELL DR
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30909-9752
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3006 CARSWELL DR
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30909-9752
Practice Address - Country:US
Practice Address - Phone:706-294-0946
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-03
Last Update Date:2016-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAMT008985225700000X
384336247100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
No247100000XTechnologists, Technicians & Other Technical Service ProvidersRadiologic Technologist