Provider Demographics
NPI:1962170241
Name:FETTIG, MICHELLE (DPT)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:FETTIG
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:41818 N VENTURE DR
Mailing Address - Street 2:STE 120
Mailing Address - City:ANTHEM
Mailing Address - State:AZ
Mailing Address - Zip Code:85086-3189
Mailing Address - Country:US
Mailing Address - Phone:480-528-0631
Mailing Address - Fax:
Practice Address - Street 1:1844 E BASELINE RD STE C5
Practice Address - Street 2:
Practice Address - City:TEMPE
Practice Address - State:AZ
Practice Address - Zip Code:85283-1506
Practice Address - Country:US
Practice Address - Phone:808-331-0054
Practice Address - Fax:480-833-1312
Is Sole Proprietor?:No
Enumeration Date:2021-09-01
Last Update Date:2024-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ31952225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist