Provider Demographics
NPI:1871935775
Name:MATHIS, MICHELLE LEIGH (PTA)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:LEIGH
Last Name:MATHIS
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:619 MATHIS FARM RD
Mailing Address - Street 2:
Mailing Address - City:ROARING RIVER
Mailing Address - State:NC
Mailing Address - Zip Code:28669-8211
Mailing Address - Country:US
Mailing Address - Phone:336-984-7809
Mailing Address - Fax:
Practice Address - Street 1:619 MATHIS FARM RD
Practice Address - Street 2:
Practice Address - City:ROARING RIVER
Practice Address - State:NC
Practice Address - Zip Code:28669-8211
Practice Address - Country:US
Practice Address - Phone:336-984-7809
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-22
Last Update Date:2013-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCA5131225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant