Provider Demographics
NPI:1578673133
Name:MACDONALD, MICHELLE RENEE (MPT)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:RENEE
Last Name:MACDONALD
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1307 E PROSPECT RD STE 120
Mailing Address - Street 2:
Mailing Address - City:FORT COLLINS
Mailing Address - State:CO
Mailing Address - Zip Code:80525-1191
Mailing Address - Country:US
Mailing Address - Phone:970-460-0066
Mailing Address - Fax:970-460-0136
Practice Address - Street 1:1159 MAIN ST
Practice Address - Street 2:SUITE A
Practice Address - City:WINDSOR
Practice Address - State:CO
Practice Address - Zip Code:80550-4700
Practice Address - Country:US
Practice Address - Phone:970-460-0066
Practice Address - Fax:970-460-0136
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2017-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO9941225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
COCOB4918OtherMEDICARE GROUP PTAN