Provider Demographics
NPI:1902357254
Name:STOECKER, MICHELLE (DPT)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:STOECKER
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:MICHELLE
Other - Middle Name:
Other - Last Name:DITMARS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DPT
Mailing Address - Street 1:112 NE MADISON AVE
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61602-1109
Mailing Address - Country:US
Mailing Address - Phone:309-674-7874
Mailing Address - Fax:
Practice Address - Street 1:2338 W VAN WINKLE WAY
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61615-7483
Practice Address - Country:US
Practice Address - Phone:309-693-9189
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-10-21
Last Update Date:2016-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070022602225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist