Provider Demographics
NPI:1992889745
Name:URSILLO, MICHAEL ANTHONY (MS PT)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:ANTHONY
Last Name:URSILLO
Suffix:
Gender:M
Credentials:MS PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3680 N WICKHAM RD STE B
Mailing Address - Street 2:
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32935-2327
Mailing Address - Country:US
Mailing Address - Phone:321-255-5500
Mailing Address - Fax:
Practice Address - Street 1:3680 N WICKHAM RD STE B
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32935-2327
Practice Address - Country:US
Practice Address - Phone:321-255-5500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-25
Last Update Date:2024-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY014155225100000X
CT005142225100000X
FLPT24961225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist