1184286015 NPI number — MICHELLE METTE FORMAN PT, DPT

Table of content: MICHELLE METTE FORMAN PT, DPT (NPI 1184286015)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1184286015 NPI number — MICHELLE METTE FORMAN PT, DPT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
FORMAN
Provider First Name:
MICHELLE
Provider Middle Name:
METTE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PT, DPT
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
METTE
Provider Other First Name:
MICHELLE
Provider Other Middle Name:
MARIE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
PT, DPT
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1184286015
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/15/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5310 KIETZKE LN STE 104
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
RENO
Provider Business Mailing Address State Name:
NV
Provider Business Mailing Address Postal Code:
89511-2043
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
775-348-8800
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
9990 DOUBLE R BLVD STE 200
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
RENO
Provider Business Practice Location Address State Name:
NV
Provider Business Practice Location Address Postal Code:
89521-4833
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
775-348-8800
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/01/2019

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 225100000X , with the licence number:  3465 , registered in the state of NV ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 37229 . This is a "CA LICENSE" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: 3564 . This is a "NV LICENSE" identifier , issued by the state of ( NV ) . This identifiers is of the category "OTHER".