Provider Demographics
NPI:1992106736
Name:DUCKWORTH, MICHAEL WESLEY (PT)
Entity type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:WESLEY
Last Name:DUCKWORTH
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1458 W POPLAR AVE
Mailing Address - Street 2:
Mailing Address - City:COLLIERVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:38017-0630
Mailing Address - Country:US
Mailing Address - Phone:901-759-5491
Mailing Address - Fax:901-759-5493
Practice Address - Street 1:1458 W POPLAR AVE
Practice Address - Street 2:
Practice Address - City:COLLIERVILLE
Practice Address - State:TN
Practice Address - Zip Code:38017-0630
Practice Address - Country:US
Practice Address - Phone:901-759-5491
Practice Address - Fax:901-759-5493
Is Sole Proprietor?:No
Enumeration Date:2014-09-11
Last Update Date:2014-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN88032251X0800X
MS45892251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic